Community Support Services Referral Form

Program Choice

All programs are provided in Halton Region

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
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?Required

Yes
No

Client Drives

Client no longer/doesn’t drive

Client Information

Client NameRequired

First Last

GenderRequired

Date of Birth:Required

AddressRequired

Street Address Address Line 2 City Province Postal Code

PhoneRequired

Email

Languages Spoken

Client LivesRequired

Alone
With Spouse
With Family
With Children Under 18
Retirement Home

Widowed?

Smokes?Required

Pets?Required

If yes, type of pet:

Primary Contact

Caregiver Name

First Last

Caregiver PhoneRequired

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 NameRequired

First Last

Relationship to ClientRequired

Substitute Decision Maker?Required

Main PhoneRequired

Work Phone

Mobile Phone

Email

Referral Information

Who is making this referral?Required

Referral NameRequired

First Last

Referral PhoneRequired

Referral EmailRequired

Referral Organization (if applicable)

Referral Position (if applicable)

Reason for ReferralRequired

Approvals

Client has approved this referral?

Substitute Decision Maker (SDM) has approved this referral?

Permission to SubmitRequired

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

URL

This field is for validation purposes and should be left unchanged.

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