Visiting Services Referral Form

Referral Intake Form

* indicates a required field

Referred by*:

Your email*:

Your contact number*:

Date (if your browser has a date entered as a placeholder, please enter todays date)*:
_________________________

Relationship to Client:*
ClientCaregiverFriendFamily MemberHealthcare ProviderOther

Client Information

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

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

Family and/or Caregiver Information

Name*:
Relationship*:
Contact*:

Name:
Relationship:
Contact:

Name:
Relationship:
Contact:

Medical Information

Diagnosis*:
Is client aware of diagnosis*?YesNo
Is family aware of diagnosis*?YesNo
Anticipated prognosis:
Is client aware of prognosis?YesNo
Is family aware of prognosis?YesNo

Healthcare Provider Information

Provider/Agency:
Contact Information:
Comments:

Provider/Agency:
Contact Information:
Comments:

What services are you making the referral for?* (check all that apply)
Caregiver ConnectionCaregiver's CornerComplementary TherapyFootprints Legacy ProjectSupportive CounsellingVolunteer Visiting Services

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

Other Information:

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