Forms

Application for FASD Clinic Services

The Northwest Central Alberta FASD Service Network coordinates community-based FASD assessment and diagnostic services and intervention planning for children and adults prenatally affected by alcohol exposure.
FASD assessment and diagnostic services are based on the Canadian Medical Guidelines established for diagnosing Fetal Alcohol Spectrum Disorders and are provided by a multi-disciplinary team of professionals specifically trained in the field of FASD assessment and diagnoses.
Click on links below to access application forms for FASD assessment and diagnostic services.  Please note that there are forms to fill out for a child and there are separate forms for an adult.
Once completed, please forward this referral package to the Northwest Central Alberta FASD Services Network office
by one of the following 3 methods:
fax 1-855-962-3273
or by
mail to:
 ATTN:  Sharon Pearcey, Clinic Coordinator
NWC Alberta FASD Services Network
Box 5389
Westlock, Alberta
T7P 2P5
Or
For more information or to inquire about the FASD clinic process please email the Clinic Coordinator, Sharon Pearcey at sharonp@nwcfasd.ca or call 780-284-3415

Requests for Application

Leadership Member Form