Unsure about how to fill out this form? Please give us a call for assistance.

  • Whitehorse (867) 456.8182
  • Kwanlin Dün (867) 633.7820
  • Toll-free 1.866.835.8386


Below is our referral form. Once you have submitted the referral, you will receive a phone call within 2 weeks. If you have a question in the meantime, have trouble competing the form or have not received a call within 2 weeks of the referral, please contact us.

Child's details

Parent or guardian details

Where we can leave a message, if necessary.

Second parent or guardian details

(if applicable)

Where we can leave a message, if necessary

Some more details

Check all that apply
Do they identify as Métis, Inuit or First Nation? If First Nation, please indicate which one.
If this form is being completed by someone other than the child's parent or guardian, please complete this section.
Examples: parent, nurse, support worker, grandparent.