Supportive Care Intake Form
*Indicates required question
Email
*
example@example.com
Welcome
Stedman Community Hospice offers diverse and accessible supportive programs to Brant, Haldimand, and Norfolk counties free of charge. If you are interested in participating in one of our support groups, we kindly ask that you complete the following intake form. The information you provide will help us better support you through your caregiving journey. Please know that all information provided will be kept strictly confidential.
I consent to sharing the following information with the Stedman Community Hospice Supportive Care Team
*
Yes, I consent
No, I do not consent
Caregiver Contact Information
Name
*
First Name
Last Name
Phone Number (home)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (cell)
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred method of contact
*
Home phone
Cell phone
Email
Date of Birth
*
-
Month
-
Day
Year
Date
Pronouns (she/her, he/him, they/them etc.)
*
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Support Needs & Patient Information
Which support group are you interested in at this time? (choose all that apply)
*
Support During Serious Illness - Educational Series
Care for the Caregiver Support Group
Have you ever participated in a support group/program?
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Yes, at Stedman Community Hospice
Yes, but not at Stedman Community Hospice
No
How did you hear about the support services offered at Stedman Community Hospice?
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From a relative/friend
From a health care professional
From Stedman Outreach Team
From the Stedman Community Hospice Website
From the Stedman Community Hospice Facebook/Instagram Page
Other
Name of patient
*
Patient's date of birth
*
-
Month
-
Day
Year
Date
The patient is my...
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Spouse
Parent
Child
Sibling
Grandparent
Friend
Other
Is the patient receiving palliative care?
*
Yes
No
If yes, through who is the patient receiving palliative care?
Through Stedman Community Hospice Outreach Team
Through Ontario Health at Home
Through a hospital
Other
How do you feel you are coping? On a scale of 1-10, select the number that best describes how well you are coping today.
*
Not
1
2
3
4
5
6
7
8
9
Coping well
10
1 is Not , 10 is Coping well
What are your current coping mechanisms/strategies?
*
Are you currently or have you ever seen a mental health professional?
*
Yes
No
If yes, please elaborate:
Is there any other information you would like the Supportive Care Team to know?
Submit
Should be Empty: