CanTeen Referral Form

Please take a moment to read the referral guidelines under before completing the form below. The information provided is of course strictly confidential and is encrypted by SSL (similar to your Internet Banking security). Please note that the questions marked with an asterisk* are required.
  • Young Person's Details

  • Please select that which best describes the young person's situation.
  • Parent or Guardian's contact (if applicable)

  • Referrer's Details

    Which resources will be most useful (tick all that apply)
  • This field is for validation purposes and should be left unchanged.