Community Support Services Referral Form Program ChoiceProgram Choice: * Required Friendly Visiting Memory Visiting Tele-Touch Home Support Exercise Program Bereavement Support Hospice Care Wellness - Music Therapy Wellness - Complementary Therapies Bereavement Support Only: * RequiredType of Loss:Date of Loss: Hospice Visiting Only - Client has DNR? * RequiredNoYesClient InformationClient Name * Required First Last Gender * RequiredFemaleMaleOtherDate of Birth: * RequiredAddress * Required Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone * RequiredEmail Languages SpokenClient Lives * RequiredAloneWith SpouseWith FamilyRetirement HomeOther Other Widowed?NoYesSmokes? * RequiredNoYesPets? * RequiredNoYesIf yes, type of pet:Primary ContactPrimary Contact * RequiredClientCaregiverCaregiver Name * Required First Last Caregiver Phone * RequiredCaregiver Email Medical InformationWhat health concerns should we be aware of? Mobility Incontinence Dementia Hearing Speech Vision None Other health concerns:Client is on a crisis list for long term care Yes No Other health services in the home: Personal Support (PSW) Nursing PT - Physiotherapy OT - Occupational Therapy None Other Most Involved PhysicianPhysician NamePhysician PhoneEmergency ContactEmergency Contact Name * Required First Last Relationship to Client * RequiredSubstitute Decision Maker? * RequiredNoYesNot ApplicableMain Phone * RequiredWork PhoneMobile PhoneEmail Referral InformationWho is making this referral? * RequiredSelfFamily MemberFriendProfessionalOtherReferral Name * Required First Last Referral Phone * RequiredReferral Email * Required Referral Organization (if applicable)Referral Position (if applicable)Reason for ReferralApprovalsClient has approved this referral?YesNoSubstitute Decision Maker (SDM) has approved this referral?Not ApplicableYesNoPermission to Submit * Required I agree 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.NameThis field is for validation purposes and should be left unchanged.
