Residence Intake Forms

Bethell Hospice > Residence Intake Forms

If you or someone you know is in need of residence support from Bethell Hospice, please select and complete the appropriate referral. Please provide as much information as you are able.

All Bethell Hospice programs and services are provided at no cost, thanks to the generous support of our community, donors, and community partners.

Referrals to our Bethell Hospice Residence Care 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 submit a Residence Referral Form, or Residence Admission Agreement Form, please contact Amita Patel or Dorothy Rankin, Intake Coordinators at 905-838-3534, ext. 2240, or [email protected]

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.

Hospice Residence Referral Forms

Hospice Residence Referral (Individual or Caregiver)

Hospice Residence Referral (Medical Provider)

Residence Consent Forms

Once your Residence Referral Form has been accepted, both the Consent Service Agreement for the Hospice Residence Program and the Bethell Hospice Foundation Form will need to be completed. See below.

CONSENT SERVICE AGREEEMENT Hospice Residence Program

Form 1 of 2. Please also complete the next form, Resident/Community Client Consent for Bethell Hospice Foundation below.

RESIDENT CONSENT FOR BETHELL HOSPICE FOUNDATION

Form 2 of 2.

For more information, or should you require assistance in completing a form, please contact our Intake Coordinators at 905-838-3534, ext. 2240, or email [email protected]

email consent & use Form

Please complete this form to allow us to permit communications to you via email.