Child Care Support Referral (CCSF) 2012
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To be completed by the Child Care Supervisor/Provider, Parent and Special Needs Resource staff. Please print.
Child Care / Provider information:
Child Care / Provider name Location ID number
Address Postal code Phone number
Date started at centre (dd-mmm-yyyy) Supervisor name
Child information:
Child’s name (first, last) Date of birth (dd-mmm-yyyy)
Parent / Guardian(s) names(s) Phone number
Home address Postal code
Special Needs Resource (SNR) information:
Staff name Phone number
Agency Date SNR service started
(dd-mmm-yyyy)
Service request type: Intensive Resource Support
Child Care Support Funds
Presenting concern(s): Safety Transition support Social interactions
Skill building Physical behavior Other:
Please expand on the priority concern:
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HILD CARE SUPPORT REFERRAL FORM (CCSF) 2012
Assessment:
Has the child had an assessment? Yes No On waiting list
Date put on waiting list:
Hospital / Agency (if known):
(dd-mmm-yyyy)
If yes, type of assessment: Developmental Psychological Other (please describe below)
Date of assessment:
Location:
(dd-mmm-yyyy)
Diagnosis / Outcome / Recommendation:
School information:
Does the child attend school? Yes No
Describe school placement:
Agency involvement / in what capacity (if known):
Are any other agencies involved with the child? Yes No
Current agency involvement:
Past agency involvement:
Wait-listed for service:
Request form and Consent for Presentation must be submitted to the Resource Supervisor by the SNR staff
prior the Child Care Support meeting.
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HILD CARE SUPPORT REFERRAL FORM (CCSF) 2012
Special Needs Resource staff complete the following as they relate to the development of the child and the request for
CCSF and/or IRS:
Areas of development (be specific about strengths and needs):
Current program goals / strategies:
Goals and specific strategies that will be implemented by the program staff to support the child:
Additional information that may be having an impact on the child in the program:
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HILD CARE SUPPORT REFERRAL FORM (CCSF) 2012
Contract agreements: (please refer to the Child Care Support Guidelines)
The Child Care Centre agrees to the following:
1. The addition of CCSF and/or IRS services in the child care program.
2. To hire CCSF staff so that regular staff can provide a higher level of support to the child names in the
contract.
3. To provide direct supervision to CCSF staff.
4. Payment to CCSF staff according to typical pay schedule and rate indicated on request form.
5. Sign and submit documentation required for CCSF payment in a timely manner.
6. Involve and inform families in all aspects of IRS service.
7. Promptly communicate any concerns or questions to the Special Needs Resource staff and/or the Intensive
Resource staff.
8. On-going collaboration and consultation with the Special Needs Consultation service and/or Intensive Support
service regarding the child’s needs and progress.
9. Prompt notification and cancellation of CCSF staff or Intensive Resource staff when the child is absent.
Signature Date (dd-mmm-yyyy)
The Home Child Care Agency agrees to the following:
1. Knows about the IRS support request to the Home Child Care Provider listed on the form.
Signature Date (dd-mmm-yyyy)
The Home Child Care Provider agrees to the following:
1. The addition of Intensive Resource Support services in their home.
2. To involve and inform families in all aspects of IRS service.
3. To promptly communicate any concerns or questions to the Special Needs Resource staff and/or the
Intensive Resource staff.
4. On-going collaboration and consultation with the Special Needs Consultation service and/or Intensive Support
service regarding the child’s needs and progress.
5. Prompt notification and cancellation of IRS staff when the child is absent.
Signature Date (dd-mmm-yyyy)
Parent / Guardian agree to the following:
1. The addition of CCSF staff and/or Intensive Resource Support services in the child care program.
2. To attend initial planning meeting and subsequent review meetings.
3. To communicate with the child care Supervisor/Provider/Staff, Special Needs Resource staff and/or Intensive
Resource staff as deemed necessary.
4. To inform the Supervisor/Provider as soon as possible if child is going to be absent.
Signature Date (dd-mmm-yyyy) Signature Date (dd-mmm-yyyy)
Special Needs Resource staff agree to:
1. Organize the first planning meeting immediately after receiving notice that IRS has been approved.
2. Develop goals in partnership with parents, child care staff/provider and IRS staff as described in this
agreement.
3. Meet with the Child Care Centre/Provider, Intensive Resource staff and/or family regarding the child’s on-
going and changing needs.
4. Maintain active involvement with the child care program during the implementation of CCSF/IRS.
Signature Date (dd-mmm-yyyy)
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HILD CARE SUPPORT REFERRAL FORM (CCSF) 2012
Child Care Support Funds (CCSF)
Child Care Support Funds (CCSF) are available to child care programs that require short-term staff support to relieve
regular staff so they can assist children with extra support needs in the program.
Any other information related to the approval of CSF:
Number of hours requested:
Rate of pay per hour ($):
Any change to the rate of pay after the request has been processed must be approved by the Resource
Supervisor.
What time of day is most beneficial to deliver CCSF service?
Morning Lunch Afternoon Other:
Intensive Resource Support (IRS)
The focus of IRS staff is to build the capacity of a child care program or home child care provider, to support the
inclusion of specific children with complex and/pr intensive developmental, social, emotional or behavioral needs
through direct teaching, modeling and coaching of strategies.
The CCSF/IRS review committee will consider all applications and discuss priority if applicable. The agency providing
IRS service will prioritize service based on a number of factors (referral date, child/program needs, staff availability,
etc). The IRS agency will contact the SNR staff when service is ready to begin.
Please list below any other information related to the approval of IRS.
What time of day is most beneficial to deliver IRS service?
Morning Lunch Afternoon After-school Other:
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OMMITTEE USE ONLY
Agency to provide IRS service: Date referral accepted:
(dd-mmm-yyyy)
Notice of Collection Personal information is collected by Children’s Services Division under the authority of the City of Toronto
Act, 2006, s. 136 ©, the Day Nurseries Act, R.S.O. 1990, c. D.2, and R.R.O. 1990, Regulation 262. The information will be used
for the purpose of ensuring the delivery of high quality child care services under the Act and City Operating Criteria. Questions
about this collection can be directed to General Manager, Children’s Services, Station 1102, 10
th
Floor, Metro Hall, 55 John
Street, Toronto, Ontario, M5V 3C5, 416-392-8128
