Bethell Hospice

INFORMATION FROM PERSON MAKING REFERRAL:

Name of Referrer *

Organization (if applicable):

Date

Relation/Title

Phone

Email

INFORMATION ABOUT PERSON BEING REFERRED:

Name *

Date of Birth (MM/DD/YY)

Gender

Email

Home Address *

City *

Province *

Postal Code *

Primary Phone Number *

Secondary Phone

Emergency Contact Person:

Name

Relation

Phone

Client Type

Client with Palliative Care Needs

Caregiver Client

Bereaved Client

If requesting Palliative Client Services, please complete the section below:

Diagnosis

Date of Diagnosis

PPS (if known)

Physician/Nurse Name

Physician/Nurse Title

Phone

If requesting Caregiver Client Services, please complete the section below:

Name of Person Being Cared For

Diagnosis

Relation

If requesting Bereavement Client Services, please complete the section below:

Name of Deceased

Date of Death

Relation

Additional Notes

Please forward a copy of this completed form to the following email address for my records: *

Community Program Referral Form