Make a Referral

Would you like to remain anonymous?
YesNo

Your name

Agency/Organization (if applicable):

Relationship to child/family:

Phone Number

Email Address

Can we contact you to follow up?
YesNo

Please list all children, parents, caregivers, and household members involved:

Contact Information (if known)

Address
Phone Number(s)
Email Address(s)

Cultural Information (if known)

First Nation, Inuit, Métis, or Community Affiliation:

Primary Language(s) Spoken in the Home (if known):

Reason for Referral

Please describe your concerns in detail, including:
• What are your main concerns?
• What do you believe may be happening?
• How long have these concerns been present?
• Frequency and recent occurrences (if known)
• Impact on the child(ren) and/or family
• Any immediate safety concerns

Strengths and Support

• What is going well for the child/family?
• Strengths or protective factors you observe
• Existing supports (family, community, professionals, services)

Outcome Sought

What are you hoping will happen as a result of this referral?

Submit