Request Services

Anyone may request services on behalf of a child or youth, therefore we have created this electronic request form for your convenience. If you are requesting service on behalf of child or youth and are not the legal guardian we would appreciate it if you would let the guardian of the child or youth know.

Submitter is:

Child's Caregiver/Guardian

A Service Provider

Child's First Name

Caregiver First and Last Name

Relationship to Child

Caregiver Home Address

Caregiver's Email Address

Submitter's First and Last Name

Submitters's Service Role

Submitter's Email Address

Child's Last Name

Select if applicable:

Aboriginal

Metis

Language Spoken:

Child's Date of Birth

Caregiver's Phone Number

Caregiver Mailing Address (if different)

Caregiver's Email Address Confirmed

Service Provider/Agency/Program

Submitter's Phone

Confirmation of Email Address

Brief Description of Child's Needs:

I have read and agree to the Privacy Policy and Terms of Service as linked in the footer below :Terms of Service

Thanks for submitting!