CURRENT REGION: Regina 306-347-5020

Referral Forms

ECIP has an open referral policy which means that anyone involved in the care of the child can refer to our program. If you're not yet sure if you should refer a child to our program, learn about us here or read more about our Core Services.

The information on this online referral form goes directly to our main email address, please provide the information you feel comfortable sharing with our program. We will be contacting you in the near future to discuss your child's needs further.

If you prefer to print off and mail or scan the referral directly to our program, scroll down to the bottom of the page to download our forms.

Online Referral Form

Referral for (please check one of the following): ^*

Early Childhood Intervention Services – Home based visiting (0-6 years of age) Specialized Support Program - Service coordination with Indigenous Services Canada (6-17 years of age)

Child's Information

Child/Youth's Name: ^*

Gender: ^* Male Female Not Specified

Birth Date: ^*

Age at Referral ^*

SHS Number:

Treaty Number:

Band:

Physical Address: ^*

Postal Code: ^*

Mailing Address (if different than above):

Languages spoken at home:

Caregiver 1 Information

Parent/Caregiver 1:

Relationship to child/youth:

Address:

Postal Code:

Telephone:

Email:

Preferred Contact:

Phone

Text

Email

Caregiver 2 Information

Parent/Caregiver 2:

Relationship to child/youth:

Address:

Postal Code:

Telephone:

Email:

Preferred Contact:

Phone

Text

Email

Referral

Reason for Referral (please check all which apply): ^* Diagnosis Experiencing Delay At Risk for Delay

Description: ^*

ECIP Support

Please identify the primary areas for ECIP support (please check all which apply): ^*

Child Development Community Connections

Service Coordination Family Support

Description: ^*

Organization Information

To be completed if referred by an organization:

Referral Name:

Position:

Organization:

Address:

Postal Code:

Telephone:

Fax:

Email:

Has this referral been discussed with the parent/caregiver? Yes No

^* By providing this information, you consent to ECIP Regina contacting you to follow up on this referral.

Printable Form

Click the button below to download a printable (PDF) version of the form:

Referral Form

Vision

ECIP organizations share the vision that “All families have the capacity to meet the developmental needs of their children within the community of their choice.”

About ECIP

Goals

Enhance childhood development.
Identify family needs and strengths.
Support and empower families.
Provide links to community services.

Core Services

Funding

ECIP is a nonprofit organization funded through the Saskatchewan Ministry of Education, Health Canada and through donations and grants.

Sponsor Us