Information for Provincial ASD Consultants

Information for ASD Consultants

Northern Autism Service – Saskatchewan

Referrals

Please use the referral form below to submit applications for assessment and/or therapy. This form can only be used by Provincial ASD Consultants in Saskatchewan. Questions? Please call us.

ASD Consultant Intake Form

Child Information

Child's Full Name

Child's Age

Is this child First Nations?

Required to apply for NIHB Funding.

Enter child's Birthday

Enter Child's Treaty Card Number

Required to apply for NIHB Funding.

Does the Child Communicate through Speech?

Is the Child in School / Daycare / Pre-K?

Parent / Caregiver Information

As soon as the referral is approved, the parent will receive an automated processing notification via email. Please ensure that the email and phone number are entered correctly.

Parent First Name

Parent Last Name

Address

Address Line 1

Address Line 2

City / Town

Province

Postal Code

Parent's Best Email

The parent will receive emails about the referral confirmation as well as about making an intake appointment.

Parent's Best Phone Number

The parent may receive a text message about making an intake appointment.

Referring Provincial ASD Consultant

As soon as the referral is approved, the ASD consultant will receive copies of the completed form as well as the handouts and letter that were emailed to the parent.

ASD Consultant Name

Referral for:

Please attach the (CASD) Checklist for Autism Spectrum Disorder Score Report to this referral request. PDF Only

Choose File

ASD Consultant's Best Email

Repeat ASD Consultant's Best Email

Any additional information

By submitting this form:

I affirm that I have obtained consent from the child's parent or caregiver to share relevant information with STG Health Services Inc.
I acknowledge that STG Health Services Inc. will complete a prior approval with NIHB for funding related to intake and assessment services for the child named above. I also confirm that the information provided will be utilized to generate a quotation for the JP application.
Submitting this form will transmit my information to STG Health Services Inc.
Any referrals from children outside the Northern area will be deleted without prior notice.
Parents will receive an email confirmation of the referral to STG Health Services.
I acknowledge that STG Health Services Inc. is a private corporation providing mental health services in Saskatchewan and is not affiliated with the SHA or the provincial Autism Consultants.
I understand that submitting this form does not equate to crisis management or urgent mental health support. If the child requires immediate assistance, please call Health Line 811 or contact 911.