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Referral Form

The following criteria must be met before AEI can proceed with the intake:

  • Must be 18 years old or older and have a  primary  diagnosis of developmental delay
  • Written verification from applicable professional will have to be supplied
  • Ready, willing, and able to work
  • Upon securing employment transportation must be provided by caregiver/ family
  • Must provide a photocopy of SIN card and M.C.P. card.

Option One: Download

Please download the following Referral Form:
- fill it out and Print a hard copy and send to us via Post or Fax 
- or press Submit by Email to send it via your email client/application

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Download Referral Form Referral Form

Option Two: Submit Online

 

FULL NAME* 
DATE OF BIRTH* 
SEX*       
CURRENT MAILING ADDRESS 
CAREGIVER(S) 
PHONE (H)* 
PHONE (W) 
SOCIAL WORKER 
SOCIAL WORKER PHONE 
OTHER INVOLVED PROFESSIONALS 
PRIMARY DIAGNOSIS (developmental disability) 
SECONDARY DIAGNOSIS (if applicable) 
NAME OF LAST SCHOOL ATTENDED 
HIGHEST GRADE COMPLETED 
OTHER TRAINING RECIEVED 
EMPLOYMENT HISTORY (paid or sheltered) 
PERTINENT INFORMATION/ COMMENTS 
Have any assessments been done on this individual?*       
REFERRED BY 
REFERRER PHONE 
SIGNATURE 
DATE 
 * mandatory
 

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