PRC Community Referral

PRC Community Referral
The Psychogeriatric Resource Consultant (PRC) role provides education and coaching to front-line staff.

PRCs support OHaH-funded agency staff working with seniors living in community where staff are experiencing challenges in care provision due to responsive behaviours.

We will work with agency care staff to identify contributing factors and assist them in understanding person-centered communication and care strategies to create a more enabling environment tailored to the individual they support.
Referral Source - Care Coordinator

Ontario Health atHome staff member submitting referral
Name:*

First NameLast Name
Email:*
Office Phone:*
Format: (000) 000-0000.
Extension:*
Cell Phone:
Format: (000) 000-0000.
Consent obtained from POA/SDM for PRC referral, including access to clients' PHI and collaboration with the relevant circle of care partners, including but not limited to OHaH, Care Agency, BSO, SMHO and Physicians.
Yes
PRC Client: Agency

OHaH Funded Front-Line Staff
Name of Agency*
Contact/Supervisor Name*
Yes
Office Phone:*
Format: (000) 000-0000.
Extension:
Cell Phone:
Format: (000) 000-0000.
Email:
Frequency and Type of Visits:
At time of referral
Reason for Referral*
Please describe any behaviour(s) of concern and areas in which agency staff require coaching and/or education
Individual Receiving Support
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender Identity*
Pertinent Diagnoses:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Language*
AloneFamilyRetirement/Assisted Living/ Supportive HousingOther
Think "P.I.E.C.E.S"
Physical, Capabilities, Environmental Information:*
Please include anything thought to be pertinent in care provision: pain management, ambulation status, continence, level of assistance with ADLs required, enabling or disabling environmental factors, etc.
Social, Intellectual, Cultural, Emotional Information:*
Please include all that is known about the individual. The more we know about their personhood, the better our strategies for support.
Alzheimer Society Niagara RegionBehavioural Supports OntarioSeniors Mental Health OutreachOther
Name of Community Team Member(s), if Selected Above:
YesNo
Thank you for your referral to the Psychogeriatric Resource Consultant program at the Alzheimer Society of Niagara.

Once your referral is processed by the PRC team, you will receive a confirmation email including PRC contact information.

The PRC will then contact the involved agency to initiate the PRC support process.
Should be Empty:

PRC Community Referral

The Psychogeriatric Resource Consultant (PRC) role provides education and coaching to front-line staff.

Referral Source - Care Coordinator

PRC Client: Agency

Individual Receiving Support