Coordinated Service Planning

What is Coordinated Service Planning?

Coordinated Service Planning (CSP) was created to support families with children/youth who have multiple and/or complex special needs. Coordinated Service Planning makes sure that all the professionals involved with your family are working together as a team towards your family's goals, and that you are kept informed of what's going on at all times. This service was started because families of children/youth with special needs were finding it difficult and complicated to coordinate multiple services and ensure the best plan of care for their child/youth.

Coordinated Service Planning was created, as a component of the Special Needs Strategy, by the Ministry of Children, Community and Social Services, the Ministry of Education and the Ministry of Health and Long-Term Care.

Who is this program for?

Families who:

have a child or youth up to 21 years of age who is still attending school
have a child or youth who has multiple and/or complex special needs
have at least two service providers involved in their child or youth's care (including schools, therapists, community supports, and medical professionals)
need extra support to navigate the system

This service is focused on your needs and is not specific to a diagnosis.

For more information, please see the information sheet for families on Coordinated Service Planning.

How do we support families?

Service Planning Coordinators will:

meet with families to help them establish their goals
connect with the professionals who work with the child/youth (including schools, therapists, community supports, medical professionals, etc.)
work to create a Single Plan of Care (SPOC)
lead a meeting with the family that brings the child/youth's professionals together as a team to discuss the family-centered goals within the Single Plan of Care (SPOC)
follow up with each professional and keep the family informed

Coordinated Service Planning will help you:

tell your story once, and be better understood by all professionals working with your child/youth
be empowered to make informed decisions about your child's care and your family's needs
get support to monitor the needs and progress of your child or youth through a coordinated service plan

How can my family be referred?

For families and caregivers

For families living in Ottawa, Prescott-Russell (PR), or Stormont Dundas and Glengarry counties (SD&G) who would benefit from Coordinated Service Planning, please fax us a copy of the referral form to 613-738-4841.

Coordinated Service Planning referral

For health-care professionals

Are you a professional working with a family who may benefit from this service? Obtain the family's consent and send in this referral form. Please fax your referral to 613-738-4841.

Once the form is received, the Access Team will follow up to finish the referral process. We will do a needs assessment to identify the best way to meet your family's needs and determine eligibility for Coordinated Service Planning.

If you have any further questions, please call intake at:

Tel: (613) 737-0871, extension 4425
Toll Free: 1-800-565-4839, extension 4425

If you live in Leeds, Lanark, and Grenville, please connect with Kids Inclusive for further information on Coordinated Service Planning.

If you live in Renfrew County, please connect with the centralized intake at Family & Children's Services of Renfrew County by calling 613-735-6866.

Coordinating Agency and Service Providers

Coordinated Service Planning is an initiative across Ontario with a total of 34 regions offering this service. CHEO is the Coordinating Agency for Ottawa, Prescott-Russell (PR), and Stormont Dundas and Glengarry counties (SD&G).

CHEO and the following service providers offer Coordinated Service Planning:

CHEO would like to thank the key partners for their help in shaping this new program, and for their continued commitment in sharing a common vision of seamless access to services for children, youth and their families.

Our key partners in Coordinated Service Planning

Ontario Autism Program - CHEO
Champlain Complex Care Program
Local Health Integration Network (LHIN)School Boards/School Authorities
Fetal Alcohol Spectrum Disorder Strategy
Moving on Mental Health

Frequently Asked Questions

Why was Coordinated Service Planning created?

Families have said they found that navigating the system was confusing and complicated when accessing services. Coordinated Service Planning was started in 2015 as part of the Ontario Special Needs Strategy.

The Ontario Special Needs Strategy is an initiative of:

The Ministry of Children, Community and Social Services
The Ministry of Education
The Ministry of Health and Long-Term Care

The Special Needs Strategy is committed to using a common approach to service coordination through all agencies based on the following values:

Family-centred/family-defined
Any door is the right door
Families tell their story once
One person to call
Flexible, individualized support for Coordinated Service Planning
Accessible service
Community vision and accountability
Shared and informed decision-making
Timely, effective, transparent information and communication
Holistic perspective that has a prevention lens

Who are children and youth with multiple and/or special needs?

Children and youth with multiple and/or complex special needs rely on many services for support (for example: rehabilitation services, autism services, developmental services, and/or respite supports). These children/youth may have difficulty in several areas, including their physical, communication, intellectual, emotional, social, and/or behavioral development.

A family of a child or youth with multiple and/or complex special needs might have a combination of any of the following:

a child/youth with multiple medical and/or complex service needs (not diagnosis specific)
more than one child/youth in the home with multiple medical and/or complex service needs
many professionals working with the child/family
bar to accessing service (financial, language, family stress, transportation).

How long can a family be supported by a Service Planning Coordinator?

The Service Planning Coordinator supports the family until they no longer need the support, and this will look different for each family. Discharge from Coordinated Service Planning may happen when:

goals are met and the family and team agree that Coordinated Service Planning is no longer needed,
the family moves away from the area served by CHEO (Ottawa, Prescott-Russell, and Stormont Dundas and Glengarry counties),
when the youth leaves school (between the ages of 18-21), or
the family asks to be discharged.

Families may re-enter the Coordinated Service Planning process as needed.

How is Coordinated Service Planning different from other services offered at CHEO or in the community?

Coordinated Service Planning may be initiated if the family is feeling overwhelmed with coordinating services and when the needs of the family go beyond the resources available through their current team. Coordinated Service Planning is not meant to duplicate services currently being used; instead it should ease communication between families and their team members. It provides the family with the chance to meet together with all of the professionals from different agencies and work towards creating a plan of care for the child/youth (known as a Single Plan of Care). Coordinated Service Planning is a formal process between CHEO, Service Providers, School Boards and Champlain Local Health Integrated Network (LHIN).