If you prefer to submit a paper referral, click here to download and print one.
Fax to 250 352 3750

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Program Referral Form

Referrals will be responded to within 5 business days. Note that some programs may have a wait list.
  • Date Format: MM slash DD slash YYYY
  • Client / Parent Name:

  • Child / Youth Name (if applicable):

  • Date Format: MM slash DD slash YYYY
  • Second Child / Youth Name (if applicable):

  • Date Format: MM slash DD slash YYYY
  • Guardian Name (if applicable):

  • Referring Worker's Name:

  • Note: All referrals will be responded to within 5 business days. Please note that some programs will have waiting lists.

  • Section Break

If you prefer to submit a paper referral, click here to download and print one.