Current Page 1 Page 2 Preview Personal information on this form is collected by Health PEI under the authority of Section 31 (c) of the Freedom of Information and Protection of Privacy Act and will be used for the purposes of providing clients with the appropriate services. Personal health information on this form is collected by Health PEI for the purposes of your care and for other purposes permitted by the Health Information Act (HIA), including the planning and management of health services. Your information will be collected, used and disclosed only as permitted by law. For more information, visit www.healthpei.ca/yourprivacy or contact CWCNnavigator@ihis.org. Identification Enter the information for the child with complex needs in the fields below. If the family has more than one child with complex needs, please complete a referral for each child that requires support. First Name Middle Initial Last Name Address 1 Address 2 City, Town, or Community Province Postal Code For example C1B 0X1 or 12345 Country Telephone Number For example 902-555-5555 Email Address A confirmation email for this form will be sent to this address. Date of Birth Who is filling out this form? - Select -Allied Health ProviderCommunity Support Worker NurseParent/Caregiver/GuardianPrimary Medical Care ProviderService ProviderOther Who is filling out the form? Please specify. Parent, Caregiver or Guardian Information Caregiver First Name Caregiver Last Name Relationship to the Child (e.g. parent, grandparent, guardian etc.) Is your address different from the child's address above? - Select -YesNo Address 1 Address 2 City, Town, or Community Province Postal Code For example C1B 0X1 or 12345 How would you like to be contacted? - Select -PhoneEmail Email Address Telephone Number For example 902-555-5555. Do you require an interpreter? - Select -YesNo What language do you require an interpreter for? Referral Information First Name Last Name Telephone Number For example 902-555-5555. Email Address Primary Caregiver's Name Would you like to discuss the referral with the navigator before this patient/client is contacted? - Select -YesNo Is the family aware that a referral has been completed? - Select -YesNo