Grey Bruce IEAPC Program Referral and Intake Form
Note: Required fields aremarked with an asterisk (*). All other fields are optional.
Client/Patient's Name
*
Date of Birth (DDMMYYYY)
*
Health Card Number (if known)
Please confirm the client meets eligibility requirements.
*
Resides in Grey Bruce
Has identified palliative care needs or would benefit from a palliative approach to care.
Has difficulty accessing mainstream palliative care services.
Is Indigenous
Is Homeless or Vulnerably Housed (unsheltered, provisionally sheltered, unstable/unsafe/inadequate permanent housing, or is at serious imminent risk of homelessness)
Is living with serious, pervasive, mental illness.
Have you received consent from your client/patient to submit this referral?
*
Yes
No
Does the client/patient consent to our team accessing their medical records?
*
Yes
No
Your Full Name
*
Your Role
*
Your Agency/Organization
*
Email Address
*
Phone Number
*
Current Living Situation
*
Living Outside
Couch-surfing (temporarily staying with friends or family)
Shelter/Respite
Motels/Hotels (not including hotel-shelters)
Transitional or Supportive Housing
Low-Income Housing
Other
Reason why this individual would benefit from a palliative approach to care?
*
Reason client/patient has difficulty accessing mainstream palliative care services?
*
Secure Fax Number
Name of client/patient's primary care provider (if known)
Names and contact information of other healthcare providers involved in client/patient's care.
Case Worker or other Community Supports for client/patient.
Self-Identified Gender & Pronouns
Preferred Language
Sex/Gender on Health Card or other ID
Does this person have a phone? If yes, please provide phone number.
Alternate Contacts (please only provide if client/patient has given consent to contact on their behalf)
Shelter/Housing Address (If no address, submit NFA)
Current location of client/patient at time of referral (hospital, TCU, home, etc.)
What is the best way for our team to connect with this client/patient?
Related Symptoms (if applicable)
Substance Use (if applicable)
Mental Health Diagnosis (if applicable)
Other Medical History
Is there anything else you would like us to know about this referral?
Submit
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