Family Health Referral

Parent / Caregiver Information

* First Name

* Last Name

* Date of Birth Month... JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day... 12345678910111213141516171819202122232425262728293031 Year... 2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904

* Sex Male
Female

* Address

* City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln

* Postal Code

* Email

* Phone
xxx-xxx-xxxx

Client consents to receiving text or email when an alternate method of communication is required to contact them

Healthcare Provider Information

* Name

* Discipline

* Email

* Phone
xxx-xxx-xxxx

Fax
xxx-xxx-xxxx

Family Information

* Is the patient pregnant? Yes, EDD:
No

Family involved with Family and Children's Services Niagara

Child is in foster / kinship care

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

• Breastfeeding
• Concerns with child's development
• Inadequate social support
• Infant feeding
• Maternal mental health concerns
• Oral health (for children 17 and under)
• Parenting
• Prenatal health / education
• Postpartum health
• Smoking cessation support (NRT)
• Toddler/Infant Sleep information

Comments

Child Information

+ 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.

Client has verbally consented to the disclosure of their personal health information for the purpose of a referral to Niagara Region Public Health

I agree to receive fax and / or email communication about this referral from Niagara Region Public Health

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.