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 Organization if 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:* Home Hospital Long Term Care Facility Home Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone*Email Hospital / Long Term Care Facility - Location Name* Hospital / Long Term Care Facility - Unit and/or Number* Client's Gender* Male Female Client's Date of Birth*Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Client's Ethnic Origin Client's Language of Choice* English French Clients Diagnosis* Cancer HIV/AIDS ALS Stroke CHF COPD MS Dementia Diabetes Heart Disease Other Other Diagnosis Client'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?* Yes No Is the client's family aware of the diagnosis and prognosis?* Yes No Is the client* Ambulatory Non-ambulatory Other 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
