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

Child's details

Parent or guardian details

One where we can leave a message, if necessary.

Second parent or guardian details

Where we can leave a message, if necessary

Some more details

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