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info@carepros.ca
(587) 800-3727
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Home
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CarePros Team
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Our CarePros
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Children’s Services
Therapeutic Foster Care
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FSCD
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24-Hour Respite Homes
Blog
Home
About
CarePros Team
Our Purpose
Our CarePros
Partners
Press & Media
Children’s Services
Therapeutic Foster Care
Youth Transition Program
FSCD
Medical Care
Behavioural Care
Out-of-Home
24-Hour Respite Homes
Blog
Find Care
CarePros Careers
Home
About
CarePros Team
Our Purpose
Our CarePros
Partners
Press & Media
Children’s Services
Therapeutic Foster Care
Youth Transition Program
FSCD
Medical Care
Behavioural Care
Out-of-Home
24-Hour Respite Homes
Blog
Home
About
CarePros Team
Our Purpose
Our CarePros
Partners
Press & Media
Children’s Services
Therapeutic Foster Care
Youth Transition Program
FSCD
Medical Care
Behavioural Care
Out-of-Home
24-Hour Respite Homes
Blog
Home
About
CarePros Team
Our Purpose
Our CarePros
Partners
Press & Media
Children’s Services
Therapeutic Foster Care
Youth Transition Program
FSCD
Medical Care
Behavioural Care
Out-of-Home
24-Hour Respite Homes
Blog
Find Care
CarePros Careers
PDD Intake Form
PDD Intake Form (1)
Demographics & Administrative
Individual's Name (Legal)
(Required)
Preferred Name / Pronouns
Date of Birth
Age
Gender Identity / Expression
PDD ID #
Date of Intake
(Required)
Referral Source / Agency
Guardianship / Legal Status
Caseworker Name & Contact
Immediate Family Contacts
Add
Remove
Name / Relationship / Phone
Primary Language / Communication Style
Interpreter Needed
(Required)
Yes
No
Cultural / Spiritual Affiliation(s)
Address / Current Residence
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Türkiye
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Complex Needs Profile
Indicate applicable areas
Diagnosed mental health disorder
History of psychiatric treatment or hospitalization
Significant risk to self, others, or property
History of self-harm or harmful behaviours
Requires specialized behaviour support plan
Chronic/multiple health conditions needing specialized oversight
Medication management concerns
Specialized equipment or ongoing medical involvement
Chronic substance use or dependency concerns
History of incarceration or justice involvement
Active involvement with multiple systems
History of service breakdown/termination
Requires 2:1 staffing/enhanced supervision/crisis planning
No complex needs identified
If complex needs identified, provide details
Non-Complex Needs Profile (check all that apply)
Non-Complex Indicators
No unmanaged mental health disorder needing specialized oversight
No significant risk beyond standard supports
No severe ongoing substance concerns
No repeated service breakdowns/terminations
No unmanaged chronic medical conditions needing specialized interventions
Limited/no justice or multi-system involvement
Support needs can be met with standard 1:1 staffing
Summary Classification
Overall presentation
(Required)
Non-Complex Needs
Complex Needs
Summary details (if Complex Needs selected)
Current Professional Contacts
Professional Contacts
Add
Remove
Type / Name / Phone / Email
Medical / Health / Wellness Information
Last Medical
Add
Remove
Last Dental
Add
Remove
Last Optical
Add
Remove
Current Medical Conditions
Add
Remove
Include 'pending diagnosis' where applicable.
Critical medical alerts / emergency considerations
Immunization status
Allergies / adverse medication reactions
Current medications (include PRNs)
Medication consents & adherence history
Counselling / mental health support history (who/when/where)
Assessments / Evaluations
Add
Remove
History of Suicidal Behaviour
History of suicidal thoughts or attempts?
Yes
Unsure
No
Last occurrence of suicidal ideation
Assessment by a professional (who?)
Actions taken to address behaviour(s)
Identified triggers
Risk & Safety Screening
Self-injury or other risk behaviours (explain)
Aggression or violence (explain)
Substance use/misuse (explain)
History of AWOL (explain)
Emergency/crisis protocols CarePros must be aware of
Will a safety plan be required?
Yes
No
Family History
Approved Family Members (contact permitted)
Add
Remove
Family of origin & relationships (as pertains to care)
Extended family & relationships
Family challenges / traumatic events
Social Supports
Approved Social Supports (contact permitted)
Add
Remove
Day Program / Employment / Volunteering / Education
Social supports (extracurricular, clubs, cultural, religious, friends)
Currently involved in a day program / work / volunteering?
Yes
No
If yes, where do they attend?
Last School / Educational Program
Achievements / outcomes / progress
Learning or skill-building challenges
Adaptive Functioning & Environmental Support Strategies
Developmental history (prenatal exposures, milestones)
Communication profile (language, strengths, challenges, AAC)
Sensory needs or supports (vision, hearing, sensitivities)
Adaptive aids or equipment (what/why)
Environmental adaptations/supports that help success
Effective strategies in employment/day programming
Effective strategies in home/program environments
Legal Involvement
Charges (what/when) and upcoming court dates
Undertakings or court orders (describe)
Guardian Input
Availability/interest of natural supports to participate
Hopes for outcomes from this placement
Individual’s strengths
Individual’s challenges
Effective strategies for emotional regulation / behavioural needs
Strategies for social relationships & community participation
Daily Living & Independence Skills
Effective strategies in structured/home settings
Effective strategies in structured/home or community settings
Quality of Life Domains (0–3 scale)
Home & Daily Living (0–3)
0
1
2
3
Comments: Home & Daily Living
Community Inclusion & Participation (0–3)
0
1
2
3
Comments: Community Inclusion & Participation
Health & Well-Being (0–3)
0
1
2
3
Comments: Health & Well-Being
Safety & Security (0–3)
0
1
2
3
Comments: Safety & Security
Relationships & Social Supports (0–3)
0
1
2
3
Comments: Relationships & Social Supports
Abuse Prevention, Safeguards & Rights
Informed of rights & complaint process?
Yes
No
Informed of rights re: abuse prevention, dignity, respect?
Yes
No
Informed of duty to report suspected/actual abuse?
Yes
No
Informed of Critical Incident Reporting process?
Yes
No
Confidentiality & information-sharing explained?
Yes
No
Trusted persons identified for safety/support
CarePros safeguarding responsibilities explained?
Yes
No
Informed consent signed by all parties?
Yes
No
Other important information
Review & Signatures
Review checklist
Intake summary completed
PDD Service Plan included
PDD Health & Safety documents provided (60–90 days)
Safety plan(s) created (if required)
ISP initiated (by 90 days)
ISP review date set (≤12 months)
All required signatures collected
Specialized Community Supports (if required/approved)
Access to specialized training
Risk management
Behavioural support planning
Short-term specialized supports funding (e.g., behavioural/consultative)
Procedures / Assessments
Planned Positive Procedures in place
Planned Restrictive Procedures in place
Functional Assessment required
Behavioural Support Plan (BSP) in place
PDD Risk Assessment
Signed Service Excellence (Name)
Signature Date
Δ