Referral Date * Your submission of this form will be taken to explicitly mean that the client has given their permission to make the referral and to disclose appropriate personal health information for initiating the services of Bethell Hospice (BH). Information About the Person Being Referred Fields marked with * are required. Client First Name * Client Last Name * Date of Birth GenderPlease selectUnspecifiedMaleFemaleTransgender MaleTransgender FemaleNon-Binary / Two-SpiritedIntersexPrefer not to sayOther Email Home Address * City * Province * Postal Code * Phone Number Alternate Telephone Number Emergency Contact Information Emergency Contact First Name Emergency Contact Last Name Relationship Phone Email Information for the Prospective Resident Diagnosis Date of Diagnosis PPS (if known)Please selectUnspecified102030405060708090100 Family Doctor First Name Last Name Phone Contact TypePlease selectCase ManagerCommunity OrganizationFamilyFamily DoctorFriendNurseNurse PractitionerOncologistPT/OTPalliative PhysicianPharmacistPhysicianPsychologistSchoolSocial WorkerSpecialistSpiritualTranslatorTransportationYouth CounselorOther Ontario Health at Home Coordinator First Name Last Name Phone Contact TypePlease selectCase ManagerCommunity OrganizationFamilyFamily DoctorFriendNurseNurse PractitionerOncologistPT/OTPalliative PhysicianPharmacistPhysicianPsychologistSchoolSocial WorkerSpecialistSpiritualTranslatorTransportationYouth CounselorOther Referral Source Self-Referral Referral Contact First Name * Referral Contact Last Name Contact TypePlease selectCase ManagerCommunity OrganizationFamilyFamily DoctorFriendNurseNurse PractitionerOncologistPT/OTPalliative PhysicianPharmacistPhysicianPsychologistSchoolSocial WorkerSpecialistSpiritualTranslatorTransportationYouth CounselorOther Organization (if applicable) Referral Contact Number Referral Contact Email Additional Notes Special Considerations / Referral Notes Messages sent via the internet can be intercepted. If you are concerned about providing your personal information by email or website form submission, please contact us directly at 905-838-3534 to arrange for an alternate method of communication. For more information, please refer to our Bethell Hospice Privacy Statement. Submit Referral
