Referral / Intake Form

Seniors Program - Referral / Intake Form
About You
Name*

First NameLast Name
Birth Date*

MonthDayYear
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Ethnicity*
Language*
Your preferred language
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Relationship*
What is the relationship of your emergency contact to you (spouse, partner, son, daughter, friend, etc.)?
Living Arrangements
Living Arrangement*

Live AloneWith Spouse / PartnerWith Family / FriendWidowedAssisted LivingHospitalOther
Do you have access to the Internet?*

YesNo
Ways you have access to the Internet?*

Computer or LaptopiPad or TabletSmartphoneOther
Do you have any pets?*

YesNo
Are you a smoker?*

YesNo
Do you use any other in-home services?*

Personal Support Worker (PSW)Nursing ServicesPhysiotherapyOccupational TherapistNoOther
Medical Information / Concerns
Medical Information
Please provide us with any medical information that would help us find you the best programs & support.
Health Concerns

Please tell us about any health concerns you may have.
Mobility*

NoOther
Vision Impairment*

NoOther
Hearing Impairment

NoOther
Speech Impairment*

NoOther
Please list any allergies that require regular treatment and medication:
Seniors On the Go

This is to be completed if you, or the person acting as the Substitute Decision Maker (SDM), if you wish to use Re-Imagine Ontario's SeniorsOnTheGo service.
Do you want to use the Seniors On the Go service?

YesNoPerhaps in the future
Please explain why you need this service
Example: number of times per week or per month, current difficulties with transportation arrangements, where you need to be transported, etc.
Your Income Situation

Facing financial difficultiesUnsure if I would qualify for this serviceUnable to use other transportation servicesOther
Authorization
Are you completing this form for yourself or are as a Substitute Decision Maker (SDM)?*

MyselfSDM on behalf of client
SDM has provided consent for referral to Re-Imagine Ontario?

YesNo
Referee's Name

First NameLast Name
Referee's Title
Referring Organization's Name
Referee's Email
example@example.com
Referee's Phone Number

Area CodePhone Number
Today's Date*

YearMonthDay
Should be Empty:

Seniors Program - Referral / Intake Form

Emergency Contact Information

Living Arrangements

Medical Information / Concerns

Health Concerns

Seniors On the Go

Authorization