Register for our ESI/SCERTS QuickStart™ Autism Navigator® Program

To complete this form, you will need:

Your child’s Ontario Autism Program (OAP) Client Information Number.

Please be aware:

For this program your child needs to be under 36 months of age prior to starting the program.
If your child is 36 months of age or older, please note that the OAP offers additional Caregiver-Mediated Early Years Programs for children up to 48 months.

"*" indicates required fields

OAP Client Information Reference # OAP00

Client's First and Last Name*

Gender*

DOB*

Language(s) spoken*

Program Requested*

Referral Source

Client address*

Caregiver #1

Name*

First Last

Child lives with this adult*

Preferred Phone*

Secondary Phone (optional field)

Email address*

Caregiver #2

Is there a second caregiver?

Yes

No

Name*

First Last

Child lives with this adult*

Preferred Phone*

Secondary Phone

Email address*

Please upload proof or a screenshot of your OAP #*

Max. file size: 128 MB.

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