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–
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–
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Hospice and Bereavement
–
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–
Palliative care consultation and education for care providers in Halton, Peel and Dufferin regions.
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Kids Anticipatory Grief & Bereavement Referral
Kids Anticipatory Grief and Bereavement Referral
Program Choice
(Required)
Anticipatory Grief (Understanding Illness)
Bereavement Support
Type of support requested
(Required)
One-on-one support for child or youth
Parent/Caregiver consultation
Information/education
Are you registering more than one child?
(Required)
Yes
No
Parent / Guardian Information:
Name
(Required)
First
Last
Relationship to children
(Required)
Address
(Required)
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone
(Required)
Email
Date of Birth
- must be mm/dd/yyyy format
MM slash DD slash YYYY
Language Spoken
(Required)
Does anyone in your household smoke?
Yes
No
Are there pets in the home?
Yes
No
What kind of pet(s)?
Child / Youth Information:
Name
(Required)
First
Last
Date of Birth
- must be mm/dd/yyyy format
MM slash DD slash YYYY
Age
Gender
(Required)
Male
Female
Trans
Prefer not to say
Other
Child / Youth Information:
Name
First
Last
Date of Birth
- must be mm/dd/yyyy format
MM slash DD slash YYYY
Age
Gender
Male
Female
Trans
Prefer not to say
Other
Child / Youth Information:
Name
First
Last
Date of Birth
- must be mm/dd/yyyy format
MM slash DD slash YYYY
Age
Gender
Male
Female
Trans
Prefer not to say
Other
Child / Youth Information:
Name
First
Last
Date of Birth
- must be mm/dd/yyyy format
MM slash DD slash YYYY
Age
Gender
Male
Female
Trans
Prefer not to say
Other
Emergency Contact Information
Name
First
Last
Email
Phone
Referrer Information
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Referral Organization (if applicable)
Referral Position (if applicable)
Reason for Referral
(Required)
Approvals
Parent / Guardian has approved this referral?
(Required)
Yes
No
Permission to Submit
(Required)
Acclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking "I agree" you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8800 if you do not wish to submit this information online and we will be happy to assist you.
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