Community Support Services Referral Form

Program Choice

All programs are provided in Halton Region

Program Choice: *

Limit of two programs. Internal referrals will be made for other programs if deemed appropriate.

Friendly Visiting
Memory Visiting (early stage dementia or memory impairment)
Tele-Touch
Home Support Exercise Program
Bereavement Support
Hospice Care
Spiritual Care
Kids Anticipatory Grief and Bereavement
Wellness (Reiki, Meditation, etc.)
Music Therapy
Technology Accessibility Program (TAP)

Bereavement Support Only:

Type of Loss:	Date of Loss:

Hospice Visiting Only – Client has DNR?

Hospice Visiting Only – Prognosis?

Hospice Visiting Only – Response Time Requested?

Hospice Visiting Only – Medical Assistance in Dying (MAiD) is being considered?

Client fits within the program requirements? *

Yes
No

Client Drives

Client no longer/doesn’t drive

Client Information

Client Name *

First Last

Gender *

Date of Birth: *

Address *

Street Address Address Line 2 City Province Postal Code

Phone *

Email

Languages Spoken

Client Lives *

Alone
With Spouse
With Family
With Children Under 18
Retirement Home

Widowed?

Smokes? *

Pets? *

If yes, type of pet:

Primary Contact

Caregiver Name

First Last

Caregiver Phone *

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 *

First Last

Relationship to Client *

Substitute Decision Maker? *

Main Phone *

Work Phone

Mobile Phone

Email

Referral Information

Who is making this referral? *

Referral Name *

First Last

Referral Phone *

Referral Email *

Referral Organization (if applicable)

Referral Position (if applicable)

Reason for Referral *

Approvals

Client has approved this referral?

Substitute Decision Maker (SDM) has approved this referral?

Permission to Submit *

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Community Support Services Online Referral Form

Program Choice

Client Information

Primary Contact

Medical Information

Most Involved Physician

Emergency Contact

Referral Information

Approvals

Program Choice

Client Information

Primary Contact

Medical Information

Most Involved Physician

Emergency Contact

Referral Information

Approvals

Contact us to learn more.
905-827-8800 • 1-800-387-7127

Community Support Services Online Referral Form

Program Choice

Client Information

Primary Contact

Medical Information

Most Involved Physician

Emergency Contact

Referral Information

Approvals

Program Choice

Client Information

Primary Contact

Medical Information

Most Involved Physician

Emergency Contact

Referral Information

Approvals

Contact us to learn more. 905-827-8800 • 1-800-387-7127

Contact us to learn more.
905-827-8800 • 1-800-387-7127