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–
The help you need to care for your loved one living with dementia (such as Alzheimer disease).
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and Care
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–
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–
Care and support for those with life-limiting illnesses, their families and the grieving.
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–
Exercise programs designed to prevent falls and improve the fitness of frail older adults.
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–
Palliative care consultation and education for care providers in Halton, Peel and Dufferin regions.
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Community Support Services Referral Form
Community Support Services Online Referral Form
Program Choice
Program Choice:
*
Required
Friendly Visiting
Memory Visiting
Tele-Touch
Home Support Exercise Program
Bereavement Support
Hospice Care
Kids Anticipatory Grief and Bereavement
Wellness (Music therapy, Reiki, Meditation, etc.)
Bereavement Support Only:
Type of Loss:
Date of Loss:
Hospice Visiting Only - Client has DNR?
No
Yes
Client Information
Client Name
*
Required
First
Last
Gender
*
Required
Female
Male
Other
Date of Birth:
*
Required
Address
*
Required
Street Address
Address Line 2
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
Languages Spoken
Client Lives
*
Required
Alone
With Spouse
With Family
With Children Under 18
Retirement Home
Widowed?
No
Yes
Smokes?
*
Required
No
Yes
Pets?
*
Required
No
Yes
If yes, type of pet:
Primary Contact
Primary Contact
*
Required
Client
Caregiver
Caregiver Name
*
Required
First
Last
Caregiver Phone
*
Required
Caregiver Email
Medical Information
What 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 Physician
Physician Name
Physician Phone
Emergency Contact
Emergency Contact Name
*
Required
First
Last
Relationship to Client
*
Required
Substitute Decision Maker?
*
Required
No
Yes
Not Applicable
Main Phone
*
Required
Work Phone
Mobile Phone
Email
Referral Information
Who is making this referral?
*
Required
Self
Family Member
Friend
Professional
Other
Referral Name
*
Required
First
Last
Referral Phone
*
Required
Referral Email
*
Required
Referral Organization (if applicable)
Referral Position (if applicable)
Reason for Referral
Approvals
Client has approved this referral?
Yes
No
Substitute Decision Maker (SDM) has approved this referral?
Not Applicable
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.
I agree
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
Program Choice
Program Choice:
*
Required
Friendly Visiting
Memory Visiting
Tele-Touch
Home Support Exercise Program
Bereavement Support
Hospice Care
Kids Anticipatory Grief and Bereavement
Wellness (Music therapy, Reiki, Meditation, etc.)
Bereavement Support Only:
Type of Loss:
Date of Loss:
Hospice Visiting Only - Client has DNR?
No
Yes
Client Information
Client Name
*
Required
First
Last
Gender
*
Required
Female
Male
Other
Date of Birth:
*
Required
Address
*
Required
Street Address
Address Line 2
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
Languages Spoken
Client Lives
*
Required
Alone
With Spouse
With Family
With Children Under 18
Retirement Home
Widowed?
No
Yes
Smokes?
*
Required
No
Yes
Pets?
*
Required
No
Yes
If yes, type of pet:
Primary Contact
Primary Contact
*
Required
Client
Caregiver
Caregiver Name
*
Required
First
Last
Caregiver Phone
*
Required
Caregiver Email
Medical Information
What 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 Physician
Physician Name
Physician Phone
Emergency Contact
Emergency Contact Name
*
Required
First
Last
Relationship to Client
*
Required
Substitute Decision Maker?
*
Required
No
Yes
Not Applicable
Main Phone
*
Required
Work Phone
Mobile Phone
Email
Referral Information
Who is making this referral?
*
Required
Self
Family Member
Friend
Professional
Other
Referral Name
*
Required
First
Last
Referral Phone
*
Required
Referral Email
*
Required
Referral Organization (if applicable)
Referral Position (if applicable)
Reason for Referral
Approvals
Client has approved this referral?
Yes
No
Substitute Decision Maker (SDM) has approved this referral?
Not Applicable
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.
I agree
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.
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or
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