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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.

Personal Information and Privacy

Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.

Freedom of Information

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email foi@niagararegion.ca or call 905-980-6000 ext. 3779.

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