Referral Disclaimer


Who is this On-line referral for:

This On-Line Speech and Language Referral Form is only for families who want to access Speech Services Niagara preschool speech and language services. Only referrals received by a child’s legal guardian will be accepted. Deadline for parent referral is August 31st of the year the child is eligible to start their first year of Full Day Kindergarten (previously known as Junior Kindergarten).

If your child is attending school please contact your classroom teacher or principal for information on what services may be available to you from your local school board.

Why we have an on-line referral option:

The opportunity for you to provide this information to us on line is being offered as an alternative option for making a referral. You may choose to call our intake line directly at 905-688-1890 ext. 151(St. Catharines and Grimsby) ext. 168 (Niagara Falls, Welland, Port Colborne and Fort Erie and all Francophone referrals) and provide the same information over the phone. All electronic submissions are placed in order of the date and time received.

What we do with the information we collect:

The personal data collected on the on-line Speech Services Niagara Referral Form is used to determine your eligibility for admission, to assist the speech pathologist in preparing for your child’s speech and language assessment and to ensure that we are communicating with a legal guardian. We will also use this information to contact you to arrange for your child’s appointment for a speech and language assessment. Some of the information is also required by the Ministry of Children and Youth Services for any family receiving services and programs from this agency. The information is kept confidential and stored in a secure electronic database. No names or information that could identify you or your child is provided to the Ministry.

  • The Niagara Children’s Centre is the Health Information Custodian. They take steps to protect your personal health information from theft, loss and unauthorized access, copying, modification, use, disclosure and disposal. For more information regarding privacy policies at Niagara Children’s Centre please visit
  • They conduct audits and complete investigations to monitor and manage our privacy compliance.
  • They take steps to ensure that everyone who performs services for us protects your privacy and only uses your personal health information for the purposes you have consented to once you come in for your appointment.
  • There is a Guide to Privacy and Consent for Families, please ask your therapist for a copy or to access a copy of the guide: click here.

Is my data secure:

Upon clicking "I agree" below, you are accepting the terms of this agreement and willingly sending us your information to initiate a referral for a speech and language assessment. You will be automatically redirected to a secured web page that enhances the privacy of the data being submitted. However, Niagara Children’s Centre assumes no responsibility and shall not be liable for, any damages to, or malware that may infect or affect, your computer equipment or other property on account of your access to, use of, browsing of, or reliance upon the Site or your downloading of any materials, data, text, images, video, audio or other information from the Site.

What we are collecting:

We collect personal health information about the child and family. The personal health information we collect may include, for example, name, date of birth, address, health and developmental history, records of visits to the Niagara Children’s Centre and the care children & families received during those visits. Occasionally, we collect personal health information about children & families from other sources if we have obtained parent/caregivers consent to do so, or if the law permits. Your personal health information will be contained within an electronic system. We limit collection of information to what is required to provide care to you and your child.

Why we collect it:

  • We use and disclose personal health information to:
  • Treat and care for children & families
  • Plan, administer and manage our internal operations
  • Conduct risk management activities
  • Conduct quality improvement activities, such as sending satisfaction surveys
  • Teach
  • Conduct research
  • Compile statistics
  • Fundraise to improve our healthcare services and programs
  • Get payment for treatment and care
  • Comply with legal and regulatory requirements
  • Fulfill other purposes permitted or required by law

Do I only have one chance to decide to offer my information or who can access it:

Parent/caregivers may limit access, make corrections to their children’s personal health records or withdraw consent for some or all of the above uses and disclosures by contacting us. Information on how to make changes will be provided upon request. Please note that there are legal exceptions. When you come in for your initial appointment, we will discuss the sharing of information with other programs that may be beneficial to you and your child and you will be asked to sign a consent at that time. If at any time while you are filling in our on-line referral form, you need to stop completion of the form prior to submission, please ensure you click "Cancel" in order to clear any information you have provided.

For more information about our privacy protection practices, or to raise a concern you have with our practices, please contact us:

Dorothy Harvey, privacy officer,

Manager of Rehabilitation Services

Niagara Children’s Centre

567 Glenridge Avenue
St Catharines, Ontario L2T 4C2
(905) 688-1890 X 200 (do not send personal information via email)

You have the right to contact the Information and Privacy Commissioner/Ontario if you think we have violated your rights. The Commissioner can be reached at:

Information and Privacy Commissioner/ Ontario
2 Bloor Street East, Suite 1400 Toronto ON M4W 1A8
Telephone (416) 326-3333 or 1-800-387-3333 Fax (416) 325-9195