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Referral to be completed by a community partner.

Community partners may include: Physicians, Pediatricians, Nurse Practitioners, Speech Language Pathologists, Occupational Therapists, and School Boards.

Autism Diagnostic Hub Referral Form


    Person completing this referral


    Identified concerns







    Available assessment/screening information:

    M-CHAT


    ASQ


    Nipissing District Developmental Screen


    Other Assessments

    As a Health Information Custodian within the Circle of Care, in lieu of written signature from parent/guardian/client, please check the following