Questions?

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

Referral

Below is our referral form. Please fill it out with all of the appropriate details and we'll be in touch within two weeks to follow-up.

Child's name

Date of birth

Reason for referral

Parent name

Address

City or town

Postal Code

Phone number

One where we can leave a message, if necessary.

This phone number is CellHomeWork

Second parent name

Second parent phone number

Where we can leave a message, if necessary

Is the child in a childcare program? Yes, they areNo, they're not

If the child is in a childcare program, what's its name?

Languages spoken at home

Check all that apply

EnglishFrenchOther

Other language(s), if applicable:

Is an interpreter needed? YesNo

Name of the child's doctor

Child seen at Whitehorse Health CentreKwanlin Dün Health CentreCommunity Health Centre

Name of the referral source

If this form is being completed by someone other than the child's parent or guardian, please complete this section.

Referral's relationship to the child

Does the family know about the referral? Yes, they doNo, they don't