Download Referral Form (PDF) Referral Form - September 2025Child or Youth’s InformationChild/youth’s Legal Name:First NameLast NameChild/youth’s Other Name: (if applicable)Other NameDate of BirthChild's Gender- Select -MaleFemaleAgenderBigenderTransgender MaleTransgender FemaleGenderqueerPronouns:Does your child/youth have Indigenous heritage? Yes NoChild/youth in care? Yes NoIs there a legal custody agreement or parenting arrangement in place? Yes NoIf Yes, please indicate: Sole SharedEarly Years Programs:Select Early Years Programs: Infant Development Program (Birth to 6 years old; focusing on birth to 3 years old) A Pathway to Hope (Birth to school age) Supports Available: Early Years Mental Health, Behavioural, Indigenous and Family Support Physiotherapy (Birth to school entry) Occupational Therapy (Birth to school entry) Supported Child Development (Children with developmental delays needing support to attend inclusive child care/preschool - focusing on 0 to 6, special exceptions for 7-18. Children should attend the childcare for at least 4 weeks before submitting a referral.) The Nest Positive Behaviour Support Services - Fee For Service (Autism and Behaviour program. Referrals can be made for children 2 to 5 years of age. Board Certified Behaviour Analyst, 1-to-1 BI’s. Services provided in your home and at our agency. ASD, online learning, 3rd party, and private funds accepted.)Child and Youth Programs:Select Child and Youth Programs: 2SLGBTQI+ Program (1-to-1 Support - 8 to 18 years old) 2SLGBTQI+ Program (Family Support) 2SLGBTQI+ Program (Youth Drop-In Group - 13-18 years old) FLY Youth Groups - Fee For Service (6 to 18 years old). Daytime, After school and Evening Groups, Seasonal Camps. ASD, online learning, 3rd party, and private funds accepted.)Family Support Programs:Select Family Support Programs: Keyworker; FASD & Complex Behaviour Support (Birth to 18 years old; no diagnosis is needed) Family Service Worker Program (Service for families with children and youth birth to 18 years old)Parent/Guardian 1:First NameLast NameIf interpreter is required, please indicate language:Phone/TextRelationship to Child- Select -ParentFamily MemberFoster ParentSocial WorkerStreet AddressAddress Line 1 (if no fixed address, please enter "No")CityPostal CodeMailing Address (if different)Address Line 1CityPostal CodeEmailParent/Guardian 2:Parent/Guardian 2:First NameLast NameFirst NameLast NameIf interpreter is required, please indicate language:If interpreter is required, please indicate language:Phone/TextPhone/TextRelationship to Child- Select -ParentFamily MemberFoster ParentSocial WorkerRelationship to Child- Select -ParentFamily MemberFoster ParentSocial WorkerStreet AddressAddress Line 1 (if no fixed address, please enter "No")CityPostal CodeStreet AddressAddress Line 1 (if no fixed address, please enter "No")CityPostal CodeMailing Address (if different)Address Line 1CityPostal CodeMailing Address (if different)Address Line 1CityPostal CodeEmailEmailAdditional InformationFamily DoctorPediatricianDiagnosis (if known)Reason for ReferralAttachment per referralChoose File Consent for ProgramsBecause we are family-centered, the parent or legal guardian consent is MANDATORY to receive services.Parent/Legal Guardian consent is required to receive service. I consent to receive serviceName of Parent/Legal Guardian completing this form and giving consentSubmit Form
