Contact Niagara and YWHO Niagara Region
23 Hannover Dr. Unit 8, St. Catharines ON L2W 1A3 (905) 684-3407
225 East Main St., Welland ON L3B 3W7 (905) 229-9946 ywhn.signup@gmail.com


Email: info@contactniagara.org
Referral Type:
Create a New Referral New Referral

Contact Niagara - The access point for children's developmental services including autism and FASD.
Our intake process will ensure your referral will be directed to the appropriate services.
FAX: 905-684-2728
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Referral:
Physician Referral Form ID
Date: 2025-05-17 19:51
Status: Draft
Attachment(s):
( Max File Size is 256 MB )
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Hide/ShowPatient/Client's Personal Information
Patient First Name:
Patient Last Name:
Is Client 16+?
Yes
No
DOB:
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Gender:
Address:
City:
Postal Code:
Client Phone:
Permission to call?
 
Mother/Guardian Name:
Father/Guardian Name:
Primary Phone:
Alt Phone:
Resides with:
Custody:
N/A
Joint
Sole
Unknown
Referred by:
 
Family Physician:
Phone:
Physician Billing number:
Physician Signature:
Date :
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Reason for Request (Required):
Pediatric assessment re: ASD
FASD Concerns
Psychological assessment re: intellectual disability
Other Developmental Concerns
Additional Comments:
Hide/ShowConsent and Agreement
I/, WE (Client/Patient/Guardian) AGREE TO THE EXCHANGE OF INFORMATION BETWEEN
Name of Physician
AND CONTACT NIAGARA. I ALSO AGREE TO A RESOURCE COORDINATOR CALLING ME FOR THE PURPOSE OF COMPLETING AN INTAKE.
Signature of Client
Date:
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