Referral Form – Palliative Care Support If you wish to refer a person for palliative care support, please fill out the following information. Step 1 of 3 33% Person ReferringName* First Last Organizationif applicableAddress* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Email* Referrals can only be accepted if the client (person receiving the service) or the Power of Attorney consents to the referral.* Yes, the client or Power of Attorney consents to this referral. Palliative Client InformationClient's Name* First Last Client lives at:*HomeHospitalLong Term Care FacilityHome Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone*Hospital / Long Term Care Facility - Location Name*Hospital / Long Term Care Facility - Unit and/or Number*Client's Gender*MaleFemaleClient's Date of Birth*Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Client's Ethnic OriginClient's Language of Choice*EnglishFrenchClients Diagnosis* Cancer HIV/AIDS ALS Stroke CHF COPD MS Dementia Diabetes Heart Disease Other Other DiagnosisClient's Prognosis*0 - 1 Month1-3 Months3-6 Months6-12 MonthsMore than a yearUnknownPalliative Performance Scale*100%90%80%70%60%50%40%30%20%10%0%Click here for more information on the Palliative Performance ScaleIs the client aware of the diagnosis and prognosis?*YesNoIs the client's family aware of the diagnosis and prognosis?*YesNoIs the client*AmbulatoryNon-ambulatoryOther Pertinent Information Caregiver or Power of Attorney InformationAre you the Caregiver or Power of Attorney?*YesNoName of the Caregiver or Power of Attorney First Last Address of the Caregiver or Power of Attorney Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Caregiver or Power of Attorney Email Caregiver or Power of Attorney PhoneWho should we contact regarding this request for service? Client Caregiver Power of Attorney Referrer Additional CommentsCaptcha
