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Refer a child

Before we get started

Please note that referrals cannot be made anonymously. We will not proceed without the prior knowledge and approval of the family involved. Please get the family’s permission before making your referral.

Has the child's family been made aware of this referral?

Yes, the family is aware of this referral

No, the family is not yet aware of this referral

Please get the family’s permission before making your referral.

press enter

Great! First, we need to collect some basic information about you (the referrer)

Your first nameYour last name

What is your relationship to the child you are referring?Your email addressYour phone number

Your address Info

ProvinceCity or town

Street address

Apt, suite, etc. (optional)Postal code

press enter

Perfect! Second, we need some information about the child that you’re referring

Child's first nameChild's last name

What is the child's date of birth?What is the child's illness?Is there anything else that you’d like to add? (optional)

press enter

Almost there! Third, we need to collect information for the child’s parent/guardian

Parent/guardian's first nameParent/guardian's last name

Parent/guardian's email addressParent/guardian's phone number

Parent/guardian's address Info

ProvinceCity or town

Street address

Apt, suite, etc. (optional)Postal code

press enter

Lastly, please enter the following information for the child’s doctor

Doctor's first nameDoctor's last name

Doctors's email address (optional)Doctors's phone number

press enter

and command

Thank you! Your referral has been received and will be reviewed by our team.

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Share your idea with us

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