Referral Forms

This page is for local medical professionals and clinics who may refer a patient to the program. 

Who makes referrals?

Only primary care providers in the Capital Regional District can refer a mother or parents to the program for perinatal counselling. Primary care providers include:

  • physicians
  • midwives
  • naturopaths
  • nurse practitioners
  • psychiatrists
  • public health nurses

How do I refer a patient?

STEP 1: Download & complete the form

The form is a fillable PDF that you can complete on screen, or print and then complete by hand.

STEP 2: Send the referral form

Fax it to 250-472-6762.

Or, upload the form online.

What Info is required?

A complete form has all the following information. Without this information, we cannot contact a parent and arrange a first counselling session.

  1. Direct cell number of the person who will receive counselling
  2. Baby’s DOB or expected DOB
  3. Your contact info
  4. A completed Eligibility Checklist

Some referrers send a standard clinic memo when making a referral. We accept that without a referral form as long as all the information we need is in the memo, and that any missing info is added to the message or is provided in an attachment. (e.g. the eligibility checklist).

If any info requested by the referral form is unavailable to you, please make a note of that and provide a brief explanation. Then we are aware.

Who receives referralS? What happens next?

All referrals are received and managed by Dayna McPhail, the Intake Manager for the program. Almost always, Dayna calls referred patients by the next business day to schedule a first counselling appointment.

Can I speak with someone directly?

Yes. Dayna will be happy to speak with you about a referral, or about a question you may have about the program. If you want to consult with one of the perinatal counsellors about the status of a patient’s care, Dayna can set that up.

To reach Dayna, call the program number at (250) 885-6760, and leave a message.

Dayna typically returns messages within a few hours when a message is left before 3 p.m. on a weekday. Otherwise, expect a call back in the morning of the next business day.


“Our wounds are often the openings into the best and most beautiful parts of us.”

— David Richo