REGISTRATION FOR
ADULT DEVELOPMENTAL SERVICES AND SUPPORTS

In order to register with Developmental Services Ontario Eastern Region (DSOER), the Service Navigator will need to review supporting documentation to confirm the person'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 person has a developmental disability in accordance with the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act and Regulation;
  • proof of age (document displays person's name and date of birth); and
  • proof of Ontario residency (documents displaying the person's name, address and citizenship status).

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




If you need help to fill this form, please send us an email at admin@dsoer.ca
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SECTION 1 - TO: DEVELOPMENTAL SERVICES ONTARIO EASTERN REGION.

*Referred by Agency: YesNo

Agency Name:

Contact Name:
Contact number:
Email address:

SECTION 2 - CONSENT AND SUPPORTING DOCUMENTATION

PERSON’S METHOD FOR DECISION-MAKING:

Substitute decision maker

*First Name:
*Last Name:

DOES THE PERSON (or his/her Key Contact) CONSENT TO THE REFERRAL TO DSOER?

YesNo

If YES, please complete the consent form with the person and mail, email or fax it in with other documents required to confirm eligibility to: DSOER, 200 – 150 Montreal Rd, Ottawa, ON, K1L 8H2, Fax: 1-855-858-3737, email: admin@dsoer.ca


SECTION 3 - INFORMATION ABOUT THE PERSON SEEKING SERVICES AND SUPPORTS:

*First Name:
Middle name:
*Last name:
*Date of Birth:

*I confirm that the person seeking services and supports is 16 years of age or older:
YesNo

Referral can only be submitted for individuals 16 years old or older

*Gender:

Address:

*Street#:
*Street name:
Unit#:
City:
Province:
*Postal Code:
*Area: (Choose an item.)
Home Phone:
Email address:
Cell phone:
Work phone:
Preferred Language:
Interpreter required:
YESNO
(specify language)
*Marital status:
*Mother’s maiden name (required) :

SECTION 4 - THE PERSON'S KEY CONTACT:

Relationship to the person:

First Name:
Last Name:

Address:
*Same as person registering above YesNo

*Street#:
*Street name:
Unit#:
*City:
Province:
*Postal Code:
*Area: (Choose an item)

Preferred contact number or email:

Tel:
Email:

Who to contact ?:
PersonKey Contact PersonAgency


SECTION 5 - SERVICES REQUESTED

Click here to access the service definitions

Ministry-funded services and supports
for adults with developmental disabilities

Service Navigation

Residential Support

Community Participation

Caregiver Respite

Person Directed Planning

Passport

File Update or Re-Assessment (for Adult Developmental Services and Supports)

Specialized Services

Adult Protective Services

Behavior Management

Case Management

Counseling

Dual Diagnosis Brokerage Service

Justice Brokerage

Occupational Therapy

Speech and Language Therapy

Is the service required immediately? YesNo
*If yes, indicate all reasons for urgency as listed below:

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;
OR
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.

*Provide additional details about the urgency: