Questions?

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

Referral

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

Child's name

Date of birth

Reason for referral

Parent or guardian details

Parent/guardian name

Address

City or town

Postal Code

Phone number

Where we can leave a message, if necessary.

This phone number is CellHomeWork

Second parent or guardian details

(if applicable)

Second parent/guardian name

Address

City or town

Postal Code

Second parent phone number

Where we can leave a message, if necessary

This phone number is CellHomeWork

Some more details

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

If the child is in a childcare program, what is the name of the program?

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 or health care provider

Is the child or family of Indigenous ancestry? YesNoNot sureRather not say

If yes, what is their ancestry?

Do they identify as Métis, Inuit or First Nation? If First Nation, please indicate which one.

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.

What is the referrer's relationship to the child?

Examples: parent, nurse, support worker, grandparent.

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

Questions?

Referral

Child's details

Parent or guardian details

Second parent or guardian details

Some more details

Contact us

Email

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Where we are

Mailing Address

Our hours

Monday to Thursday

Friday