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charitable registration #11928 4602 RR0001
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Home Care
–
Nursing, personal support and companions to keep you healthy and well.
Private Care
Home Nursing
Personal Support
Foot Care
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Dementia
Care
Dementia Care
–
The help you need to care for your loved one living with dementia (such as Alzheimer disease).
Adult Day Programs
JIM’s Suites (Overnight Respite)
Virtual Club
Private Respite Care
Memory Visiting
Caregiver Education
Caregiver Support Groups
Patty’s Place – New Dementia Care Centre
Social Supports
and Care
Social Supports and Care
–
Social and wellness programs for older adults.
Adult Day Program
Adult Day Program – Virtual Club
Tele-Touch
Friendly Visiting
Memory Visiting
Wellness Support
Connection In Action
Hospice and
Bereavement
Hospice and Bereavement
–
Care and support for those with life-limiting illnesses, their families and the grieving.
Hospice Care
Bereavement Support
Bereavement Support Groups
Kids Anticipatory Grief & Bereavement
Wellness Support
Candlelight Memorial Service
Hospice Palliative Helpline
Grief and Bereavement Resources
Fall
Prevention
Fall Prevention
–
Exercise programs designed to prevent falls and improve the fitness of frail older adults.
Home Support Exercise Program
Community Exercise Classes
Palliative Care
Consultation
Palliative Care Consultation
–
Palliative care consultation and education for care providers in Halton and Peel regions.
Consultations
Education
Fundamentals of Hospice Palliative Care
Advanced Palliative Practice Skills (APPS)
Comprehensive Advanced Palliative Care Education (CAPCE)
Pain Assessment and Management
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Clients
Current Clients
–
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Community Support Services Referral Form
Community Support Services Online Referral Form
Program Choice
Program Choice:
*
Required
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
Bereavement Support Only:
Type of Loss:
Date of Loss:
Hospice Visiting Only - Client has DNR?
No
Yes
Hospice Visiting Only - Prognosis?
Over 12 months
6-12 months
3-6 months
under 3 months
unknown
Hospice Visiting Only - Response Time Requested?
1-2 business days
3-5 business days
6-10 business days
Hospice Visiting Only - Medical Assistance in Dying (MAiD) is being considered?
No
Yes
Client fits within the program requirements?
*
Required
Yes
No
Client Drives
Client no longer/doesn't drive
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
Client
Caregiver
Caregiver Name
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
*
Required
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
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
Bereavement Support Only:
Type of Loss:
Date of Loss:
Hospice Visiting Only - Client has DNR?
No
Yes
Hospice Visiting Only - Prognosis?
Over 12 months
6-12 months
3-6 months
under 3 months
unknown
Hospice Visiting Only - Response Time Requested?
1-2 business days
3-5 business days
6-10 business days
Hospice Visiting Only - Medical Assistance in Dying (MAiD) is being considered?
No
Yes
Client fits within the program requirements?
*
Required
Yes
No
Client Drives
Client no longer/doesn't drive
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
Client
Caregiver
Caregiver Name
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
*
Required
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
Name
This field is for validation purposes and should be left unchanged.
Contact us to learn more.
905-827-8800
or
1-800-387-7127
Request Care Information
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