Community Care Peterborough Referral Form

Community Support Services Referral

For questions please contact the Care Navigator for Central Intake at 705-875-5588 or intake@commcareptbo.org
Community Care Peterborough needs your permission to collect, use and disclose Personal and/or Health Information for the purposes of planning and providing care and services. Your information is private and Community Care Peterborough will not share your information outside our organization without your consent. Do you understand and consent to this? *

Yes No

Referral Source
Who referred you to us? *

Self-referral A client or patient Family member, friend, neighbour, or caregiver

REFERRING ORGANIZATION
Referring Organization *
If applicable
Name of Referring Individual *

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Who should we contact about this referral? *

The client Family Member or caregiver The referring organization
Family Member or Caregiver

First Name Last Name
Caregiver's Relationship to Client
Phone Number
Please enter a valid phone number.
Would you like to be advised of the outcome of this referral? If yes, be sure to include your contact information above. *

Yes No

REFERRING FAMILY MEMBER, FRIEND, NEIGHBOUR, OR CAREGIVER
Your Name *

First Name Last Name
Your Relationship to the Client *
Your Phone Number
Please enter a valid phone number.
Your Email
example@example.com
Who should we contact about this referral? If we are contacting you, be sure to include your contact information above.

The client Me

CLIENT INFORMATION
Client's Name *

First Name, include legal name and "preferred" name Last Name
Client's Address *

Street Address

Street Address Line 2

City Province

Postal Code
Client's Phone Number
Please enter a valid phone number.
Client's Email Address
example@example.com
Client's Date of Birth

Month Day Year
Client's Health Card Number
Which pronouns would the client like us to use to refer to them? *

he/him/his she/her/hers they/them/theirs Prefer not to say Other
Language *

English French Other

If you have questions or concerns about consenting to share your personal and health information, please contact Community Care Peterborough's Care Navigator at 705-875-5588.
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Community Support Services Referral