Logo of Developmental Services Ontario Eastern Region

In order to register with Developmental Services Ontario Eastern Region (DSOER), the intake worker will need to review supporting documentation to confirm your (the applicant's) eligibility for Ministry funded adult developmental services and supports.

The documents required to confirm a person's eligibility include:

  • a psychological assessment or report signed by a psychologist or psychological associate registered with the College of Psychologists of Ontario (or equivalent body in another province) that states the individual has a developmental disability in accordance with the Act and Regulation;
  • proof of age (document displays individual's name and date of birth); and
  • proof of Ontario residency (documents displaying the individual's name, address and citizenship status).

Do you want a copy of the referral emailed to you? If so, please enter your email below:




INFORMATION ABOUT THE PERSON SEEKING SERVICES AND SUPPORTS:

First Name:
Family name:
Date of Birth:
Gender:
Address:
Postal Code:
Home Phone:
Email:
Preferred Language:
Interpreter required:
YESNO

(specify language)


TO: DEVELOPMENTAL SERVICES ONTARIO EASTERN REGION.

Date: YYYY-MM-DD

Referred by Agency: YESNO - if no, go to Person's Key Contact

Agency name:
Area:
Contact Name:
Contact Number:
Email address:

THE PERSON'S KEY CONTACT:

Relationship to the person:

First Name:
Family name:
Address:
Postal Code:
Home Phone:
Work Phone:
Email:
Cell Phone:

Who to contact ?:
ApplicantReferentKey Contact Person


CONSENT

DOES THE PERSON (or his/her Consent Source) CONSENT TO THE REFERRAL TO DSOER?

YESNO

If YES, please print the consent form and mail or fax to:
DSOER, 200 – 150 Montreal Rd, Ottawa, ON, K1L 8H2, Fax: 1-855-858-3737, Email: admin@dsoer.ca



SERVICES REQUESTED

Residential Services

Person Directed Planning

Caregiver Respite

Community Participation

Passport

Other - please specify below

Update - please specify below

PROFESSIONAL & SPECIALIZED SERVICES

Case Management

Behavior Management

Adult Protective Services

Counseling

Dual Diagnosis Brokerage Service

Justice Brokerage

Occupational Therapy

Speech and Language Therapy


Complete only if this services is required: URGENT REFERRAL (Immediately)URGENT REFERRAL (Near Future) , because:

The person providing care is unable to continue providing care as of today; or;

I have no residence or am at risk of having no residence in the very near future

My support needs have changed, my current support arrangement may soon become untenable and my well-being is likely to be at risk; AND

My formal and informal supports are not available to reduce the risk of harm or address the need.


ADDITIONAL COMMENTS