Kids Anticipatory Grief & Bereavement Referral "Required" indicates required fields Program ChoiceRequired Anticipatory Grief (Understanding Illness) Bereavement Support Type of support requestedRequired One-on-one support for child or youth Parent/Caregiver consultation Information/education Are you registering more than one child?Required Yes No Parent / Guardian Information:NameRequired First Last Relationship to childrenRequiredAddressRequired Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneRequiredEmail Date of Birth Language SpokenRequiredDoes anyone in your household smoke? Yes No Are there pets in the home? Yes No What kind of pet(s)?Child / Youth Information:NameRequired First Last Date of Birth AgeGenderRequired Male Female Trans Prefer not to say Other Child / Youth Information:Name First Last Date of Birth AgeGender Male Female Trans Prefer not to say Other Child / Youth Information:Name First Last Date of Birth AgeGender Male Female Trans Prefer not to say Other Child / Youth Information:Name First Last Date of Birth AgeGender Male Female Trans Prefer not to say Other Emergency Contact InformationName First Last Email PhoneReferrer InformationNameRequired First Last PhoneRequiredEmailRequired Referral Organization (if applicable)Referral Position (if applicable)Reason for ReferralRequiredApprovalsParent / Guardian has approved this referral?Required Yes No Permission to SubmitRequiredAcclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking “I agree” you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8800 if you do not wish to submit this information online and we will be happy to assist you. I agree CAPTCHA