If you would like to make a referral, please fill out the Referral Form on this page, call us at 1-888-522-ATTA (2882), or download the referral form by clicking here. Privacy concerns? Click here.

Make a Referral for Wellness Services

PERSON MAKING THE REFERRAL

Who is making this referral?(Required)
SELF-REFERRAL

Contact information - Please provide at least one if available:

Is a parent/caregiver aware that this referral is being made?(Required)
Would you like confirmation that we received this referral?

CHILD/YOUTH INFORMATION

Date of Birth
Address
School

Gender Identity
Language Spoken at Home

PARENT/CAREGIVER INFORMATION - OPTIONAL FOR SELF-REFERRALS

Provide this information if available. It is optional for self-referrals. The service provider will explain whose permission is needed before services begin.

Contact information - Please provide at least one if available:

Can we leave a voicemail?
Can we email them?

WHAT SUPPORT IS BEING REQUESTED? (CHECK ALL THAT APPLY)

DALTON CLINICAL SERVICES
CULTURAL SERVICES
Children and youth may self-refer for Counselling / Mental Health Support or Cultural Programming

TELL US ABOUT THE REFERRAL

Tell us what you can. It is okay if you are unsure or do not know how to explain what is needed.
Is the child/youth receiving support from anyone else right now?