Name of person making this referral

Relationship to the client

Email

Phone number

Address

Client’s name

Client’s date of birth

What are your concerns?

Do you have concerns with other areas of development or functioning?
noyes

Does the client have any diagnoses identified by a physician?
noyes

Elgin Speech & Language Services abides by the Personal Health Information Protection Act.
Once it is submitted, your personal information is stored and not shared with any party – for any reason –
without written consent to do so, unless subpoenaed by court order. For referrals received from physicians’
offices, the referral will be confirmed with the referring party and consent will subsequently be obtained from
the family referred for service prior to the commencement of any assessment, treatment, or consultation service.