Children's Special Health Services

Program Referral Process

If you would like to refer a child or youth to Children's Special Health Services (CSHS) for financial assistance, please read the following information and fill out the PDF form below. If this form is not working for you, please submit an e-mail message directly to CSHS.

You do not have to qualify for financial assistance in order to attend a specialty clinic.  Go to the Pediatric Specialty Clinic page to obtain more information regarding clinic services.

Make a referral to CSHS for financial assistance:

  1. Download the PDF form.
  2. Enter all information requested on the form.
  3. Upon completion, the form must be printed out in order to "save" what you have entered. If you close the PDF form and don't print out what you have entered, your information will be lost. The information entered into the PDF form cannot be saved.
  4. Fill in any additional information by hand, if necessary.
  5. Mail or fax the completed form to CSHS.

You can also make a referral by using the following:

  1. Download the PDF form, print it out, fill it in by hand, mail or fax it to CSHS.
  2. Call CSHS.

When filling out the form on your computer, you can use the following tools:

  1. Click on a field with your mouse to select the field. A cursor will appear and you can type in your information.
  2. The Tab key will move you forward from field to field. Shift + Tab key will move you backwards from field to field.
  3. Delete an entry by highlighting the information and pressing delete, backspace, or just type over the highlighted information.
  4. Check boxes can be checked by clicking on the box with your mouse or by selecting the box and pressing the Enter key or space bar. (Hitting the Enter key or space bar again will remove the checkmark.)
  5. Standard Windows-based commands will work in the PDF file. Control + C will copy, Control + V will paste and Control + X will cut.

The following tools only work when the cursor is not in a field:

  1. Arrow keys right and left move page to page through the document. Arrow keys up and down scroll through the document.
  2. The Enter key will move you through the document a half-page at a time.