Health Care Professionals Referral for ServicePlease enable JavaScript in your browser to complete this form.Your organizationHealth Care Professional's Name *FirstLastJob title *Email *Phone Number *Consent received from client to share their personal and medical health information *YesNoClient's name *FirstLastClient's phone number *Client's email address *Client's address *Client's due date/child's date of birthOur services are free for IFHP (Interim Federal Health Program) clients with a valid UCI number. We also accept Manulife and Blue Cross insurance. *Yes, IFHP clientsNo, pay out of pocket or insuranceClient's UCI/Interim Federal Health Program number, if applicableFor which service(s) *Childbirth educationPostpartum educationBreastfeedingMental health counsellingOtherPlease provide a brief description of services requiredSubmit
