Community Support Services Referral Form "Required" indicates required fields URLThis field is for validation purposes and should be left unchanged.Program ChoiceAll programs are provided in Halton RegionProgram Choice:RequiredLimit 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: Add RemoveHospice Visiting Only – Client has DNR?NoYesHospice Visiting Only – Prognosis?Over 12 months6-12 months3-6 monthsunder 3 monthsunknownHospice Visiting Only – Response Time Requested?1-2 business days3-5 business days6-10 business daysHospice Visiting Only – Medical Assistance in Dying (MAiD) is being considered?NoYesClient fits within the program requirements?Required Yes No Client Drives Client no longer/doesn’t drive Client InformationClient NameRequired First Last GenderRequiredFemaleMaleOtherDate of Birth:RequiredAddressRequired Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneRequiredEmail Languages SpokenClient LivesRequired Alone With Spouse With Family With Children Under 18 Retirement Home Widowed?NoYesSmokes?RequiredNoYesPets?RequiredNoYesIf yes, type of pet:Primary ContactPrimary ContactClientCaregiverCaregiver Name First Last Caregiver PhoneRequiredCaregiver Email Medical InformationWhat 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 PhysicianPhysician NamePhysician PhoneEmergency ContactEmergency Contact NameRequired First Last Relationship to ClientRequiredSubstitute Decision Maker?RequiredNoYesNot ApplicableMain PhoneRequiredWork PhoneMobile PhoneEmail Referral InformationWho is making this referral?RequiredSelfFamily MemberFriendProfessionalOtherReferral NameRequired First Last Referral PhoneRequiredReferral EmailRequired Referral Organization (if applicable)Referral Position (if applicable)Reason for ReferralRequiredApprovalsClient has approved this referral?YesNoSubstitute Decision Maker (SDM) has approved this referral?Not ApplicableYesNoPermission to SubmitRequiredAcclaim 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