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

  • (867) 456.8182
  • Toll-free 1.866.835.8386


Fax: (867) 393.6374

Please note

The information submitted via this referral form is transmitted by email to the Child Development Centre. While measures have been taken to ensure this information is received securely, any information transmitted via email is not secure or encrypted. The information contained in this referral form is also retained in a protected database on a server located in Canada for a maximum of 4 months, after which time it is deleted. If you would prefer an alternate method to submit the referral form, please call us at 867-456-8182 and we can complete the referral over the phone, or send you a paper copy.


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.

Si vous souhaitez remplir la demande consultation en français, veuillez télécharger ce pdf à remplir et l'envoyer par courriel à

Child's details

Parent or guardian details

Where we can leave a message, if necessary.

Second parent or guardian details

(if applicable)

Where we can leave a message, if necessary

Some more details

Check all that apply
Do they identify as Métis, Inuit or First Nation? If First Nation, please indicate which one.
If this form is being completed by someone other than the child's parent or guardian, please complete this section.
Examples: parent, nurse, support worker, grandparent.