Project ImPACT Registration/Intake Form

Project ImPACT Registration/Intake Form

Date Completed:

Do you have OAP number?

Yes No

If yes, please indicate your OAP number.*

Have you received invitation letter/email from the Ministry to sign up for caregiver-mediated early years program?

Yes No

Project ImPACT program is offered for children 12 to 48 months at start of intervention.

Will your child be between 12 to 48 months on program start date?*

Yes No

Have you registered with any other programs through the OAP Caregiver Mediated Early Years (CMEY) Program, on or after April 1, 2023? Programs include JASPER, Project ImPACT, Play Project, Social ABCs, Pivotal Response Training - PRT

Yes No

Unfortunately, you are not eligible to sign up for caregiver-mediated early years programs based on answers above. Please see below for more information on eligibility. https://www.ontario.ca/page/ontario-autism-program-caregiver-mediated-early-years-programs

Client Registration

Child Name*

First Name

Last Name

Date of Birth*

Address*

Address Line 1

Address Line 2

City

Province

Postal Code

Parent/Caregiver Name*

First Name

Last Name

Phone*

Email*

Parent/Caregiver Name

First Name

Last Name

Phone

Preferred Method of Contact

Phone Email Virtual Meeting

Does your child have any allergies or medical conditions we should be aware of? (Please indicate if Epi-Pen is also required)

Save and Resume Later

Progress

Client Registration

Intake Questionnaire