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 digitally to the Northwest Central Alberta FASD Services Network office

For Pediatric referrals, please send to:

Sharon Pearcey,

780-284-3415,

sharonp@nwcfasd.ca

Forms for Children

Pediatric FASD Application Package

For Adult referrals, please send to:

Jenn Pasic

780-974-7112,

jennp@nwcfasd.ca

Forms for Adults

Adult FASD Application Package

Requests for Application

Leadership Member Form

Download
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
 
If Digital Communication is not possible, then you may mail to:
 ATTN:  Sharon Pearcey, Clinic Coordinator
NWC Alberta FASD Services Network
Box 5389
Westlock, Alberta
T7P 2P5

Referral for Support Services

Download

The Northwest Central FASD Service Network delivers community-based FASD Outreach support services to individuals and families. Services include: youth and adult mentorship programs, system navigation and community connection for caregivers of children diagnosed with FASD, mentorship program for women of child bearing years utilizing the Parent and Child Assistance Program (PCAP) mentorship mode. Click on the link below to access the referral form. Once completed, please forward this referral digitally to the Northwest Central Alberta FASD Services Network Office.

 

donnak@nwcfasd.ca   780-305-8757