Sapling Services Request Form

Parents: when filling out this form for your child, please enter your child’s name and date of birth in the personal information section. You can list yourself as the emergency contact.

If you are the client, please enter your own name and date of birth.

Please provide us with as much relevant detail as possible so that we can ensure that your family is assigned to a therapist who can meet your needs.

The following people have authority to make decisions for the child, make or change appointments or request personal health information:

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Which services are you interested in accessing?

Occupational Therapy (OT)

Physiotherapy (PT)

Speech-Language Pathology (SLP)

Social Work (SW)

Psychotherapy (SW/OT)

Sleep Support (Gentle Sleep Consultant)

Behaviour and Learning Support (Behaviour Companion)

Areas of concern (check all that apply):

Please list any medical conditions, including developmental, neurological, physical, sensory, orthopedic, or other relevant conditions. If applicable, include any diagnoses related to learning, emotional regulation, or feeding challenges.

Please select all that apply regarding the person being referred for services. These items help us identify situations that may require immediate attention or specialized care.

Mental Health & Behavioral Concerns

Consistently demonstrates violent or aggressive behavior that poses a significant risk to themselves or others

Engages in self-harm

Has expressed suicidal thoughts or ideation

Has experienced physical and/or emotional trauma

Has had previous hospitalizations related to a mental health crisis

Exhibits signs of depression or anxiety that significantly impact daily life

Has been unable to attend school due to the severity of behavioral or emotional challenges

Requires 1:1 support in school due to significant safety concerns

Has a history of elopement (running away from safe environments)

Feeding, Eating & Nutrition

Has an extremely restricted diet that is impacting growth and/or development

Has been diagnosed with an eating disorder (e.g., ARFID, anorexia, bulimia)

Has a history of frequent pneumonia or respiratory infections

Shows signs of swallowing difficulties (e.g., choking, coughing while eating)

Neurological & Medical Concerns

Has a history of seizures or other neurological conditions

Has a medical condition that requires specialized care or emergency preparedness

Has experienced a head injury or concussion

Has experienced a sudden loss of mobility, coordination, or balance, or sudden muscle weakness

Is experiencing persistent or unexplained pain (e.g., back, joints, limbs), numbness, tingling, or loss of sensation

Has experienced a sudden loss of bladder or bowel control after being previously fully toilet trained

Has had recent surgery or an acute injury requiring rehabilitation (e.g., fracture, sprain)

Speech & Communication Concerns

Has experienced a sudden loss of speech or language skills (regression)

Presents with slurred speech or facial asymmetry (possible neurological concern)

Has significant stuttering that affects communication or causes distress

Please select all the professionals who are currently part of your circle of care:

Feel free to share any details, special requests, preferences, or questions that haven’t been covered in this form. This might include:

Specific goals or concerns
Cultural or language considerations
Preferred clinician characteristics
Scheduling needs or barriers to accessing services
Anything else that would help us support you or your child

We're here to listen and tailor our approach to best support your journey.

Thank you for completing this questionnaire.

By submitting this form, you will be added to our waitlist for the requested services. We will review your responses and connect with you when availability opens up.

If you have any questions or urgent concerns in the meantime, please don’t hesitate to reach out to us at welcome@saplingtherapy.ca.

We truly appreciate your time and look forward to supporting you as part of your circle of care.

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