• A  A  A  

Home » Community Program Forms

Community Program Forms

Referrals to our Bethell Hospice Community Program can be made either by the individual seeking service or by a medical services provider. PLEASE NOTE, the online forms are currently not working. If you wish to make a new referral, inquire about one already submitted, or to submit a consent/referral form, please contact communityintake@bethellhospice.org or call 905-730-3698.

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.

Community Referral Form

Once your Community Program Referral Form has been accepted, the Community Program — Consent for Service Form will also need to be completed.

Please Note:  Attempts are made to process new referrals within 5 business days; however, there may be delays on occasion.
We appreciate your patience during these times.

Community Program Consent for Service

Parental Consent Form

Please complete this form for all minors under the age of 18

For more information, or if you need assistance in completing a form, please contact:

Natalie Talma, Psychosocial Spiritual Care Team Lead at 905-452-4979 or ntalma@bethellhospice.org

Thanks to our Funders