Bereavement Support Referral

Bereavement Support Referral Form
* indicates required fields

Referred by*:
Your email*:

Your Phone Number*:

Relationship to Client (client is the individual requiring support)*: Client(self)CaregiverFriendFamily MemberHealthcare ProviderOther

Is this referral a court mandated request? Please note: Hospice Orillia staff and volunteers are not able to provide one-on-one or group support to those who are mandated by a court order.
YesNo

Has the individual being referred, provided their verbal consent for this referral*?
YesNo

Is this referral related to a pregnancy or infant loss?
YesNo

Referral Date*:

_______________________________

Client Information

Name*:
Date of Birth:
Phone*:
Email Address:
Address:
City:
Prov, PC:

Client's Current Location*:
HomeOther (if other provide details)

_______________________________

Tell us a bit about the clients loss for which they are seeking support

Date of loss:
Relationship to the client*: SpouseParentChildFriendFamily MemberOther
Has the client received previous support for this specific loss?* YesNounsure
If yes, provide details if available:
Other important information you would like us to know:

_______________________________

Do you wish to receive the Hospice Orillia monthly newsletter to your inbox?*
YesNo