Family Health Referral

To be used by health care providers only. For all other referrals, contact Niagara Parents.

* = Required

Parent / Caregiver Information

* Date of Birth

* Sex

Healthcare Provider Information

Family Information

* Is the patient pregnant? , EDD:

Family requires support with the following (check all that apply):

Child Information

Date of Birth


+ Add another child

Additional Information

Note: Depending on the family's needs, they may be offered appointments at a clinic, educational classes, online resources and / or a home visit. Additional referrals may also be facilitated as required.

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.

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