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Maritime Services:

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Peel Children's Centre

Maritime Services For Professionals:

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If you would like to refer a client to our Moncton Residential Treatment Program or our Moncton Parent-Operated Residential Treatment Program, please fill in the form below and click SEND.

If you prefer to make a referral off-line, please use the link below to download a copy of our referral form, fill it out and fax it to: 506-386-5545.



Fields marked * are required


General Information:
* Date of Referral: (Day/Month/Year)
Personal Information
* First Name
* Last Name
* E-Mail
Information on Referral Source
* Name of Referring Agency
* Agency Address:
* Case Manager Name:
* Work Telephone of Case Manager:
Information on Youth being Referred
* Name of Youth:
* Date of Birth: (Day/Month/Year)
* Gender:
* Custody:
Information on Parent if Applicable
Parent Name:
Home Address:
City:
Province/State
Country
Postal Code/Zip
Home Telephone:
Work Telephone:
Is Parent the legal guardian?
Name of Guardian:



Download Documents:

Referral Form - (Referral_Form_en.pdf)

Download Form


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