Referral

ASSESSMENT INFORMATION FORMS

Several referral and assessment information forms must be completed before an assessment can be arranged. The forms required vary depending on the specific circumstances of the individual being referred.

Below are forms for downloading with an indication of when a form is required and who is required to complete the form.

[Please note: The forms require Adobe Acrobat to open and print. (Acrobat Reader is a free download at www.adobe.com)

For security and confidentiality reasons, the forms cannot be submitted to the Manitoba FASD Centre by email, but must be faxed or mailed.

Click here for the mailing address or fax number.

Form	To be submitted for…	To be submitted by…
Information on Referrals [Download]	Information only	For information only
Referral for Assessment [Download form]	All children referred for assessment	Physician, social worker or other professional
General Information [Download form]	All children referred for assessment	Legal guardian
Social History Information [Download form]	Children in care of Child and Family Services	Child and Family Services worker
Day Care/Preschool Information [Download form]	Children in daycare or preschool programs	Daycare director
School Information [Download form]	Youth	School principal or designate
Authorization to Release Birth Records [Download form]	All children referred for assessment	Legal guardian
Consent for Assessment [Download form]	All children referred for assessment	Legal guardian

QUESTIONS ABOUT FASD?
Call FASD Information Manitoba
1.866.877.0050