Hospice Counselling Referral

Hospice Counselling Referral Form

For anyone (regardless of age) who is diagnosed with a life limiting illness.
Referral Date*

MonthDayYear
Client's Demographic Information
Name*

First NameLast Name
Gender*
Address*

Address

Address Line 2

CityProvince

Postal Code
Phone Number*
Please enter a valid phone number.
Phone Number (Cell)
Please enter a valid phone number.
Email Address
example@example.com
Date of Birth*

MonthDayYear
Marital Status
Health Card
Health Card Version Code
Primary Language
Secondary Language
Religion/Spiritual Affiliation
Medical Information
Diagnosis/Life Limiting Condition*

CancerOrgan FailureNeurodegenerative DiseaseFrailty/Dementia/Multi-MorbidityOther (Specify below)
Diagnosis Details*
Metastatic Spread Details (if available)
Ongoing Treatment Details (if available)
Anticipated Prognosis*
Current PPS*
Client's Current Location*
Anticipated Hospital Discharge Date

MonthDayYear
(if applicable)
Primary Hospital
Palliative Physician or MRP (Most Responsible Physician)
Name and Contact Number (please follow this format: Dr. First Name, Last Name, 905-111-1111)
Ontario Health at Home Care Coordinator
Name and Contact Number (please follow this format: First Name, Last Name, 905-111-1111)
Client agreed to DNR*
Client Aware of Diagnosis*
Client Aware of Prognosis*
Reason for Referral*

CounsellingInformation/EducationSpiritual CareCaregiver SupportHUUG (Children's Grief Program)
Additional Information
Urgency of Response
Family Contact Information

1- Next of Kin/Caregiver
Name

First Name (1-NOK/Caregiver)Last Name (1-NOK/Caregiver)
Relationship to the Client
Holds POA for Personal Care
Holds POA for Property
Contact Number
Please enter a valid phone number.
Address (if different than Client address)

Street Address

Street Address Line 2

CityProvince

Postal Code
Email Address
(1-NOK/Caregiver)
Additional Family Contact Information

2 - Next of Kin / Caregiver if involved in client's care
Name

First Name (2-NOK/Caregiver)Last Name (2-NOK/Caregiver)
Relationship to the Client
(2-NOK/Caregiver)
Holds POA for Personal Care
(2-NOK/Caregiver)
Holds POA for Property
(2-NOK/Caregiver)
Contact Number
(2-NOK/Caregiver)
Email Address
(2-NOK/Caregiver)
Please List Additional Contacts (if needed)
Please Include Name, Relationship and Contact Number
NOK/Caregiver/POA Aware of Diagnosis
NOK/Caregiver/POA Aware of Prognosis
Person to Contact to Discuss Hospice Support*
Referral Source
Referral Submitted by*
First Name Last Name
Referring Organization
Other:
Organization name if not listed above
Referral Contact Number*
Referral Email
Should be Empty:

Hospice Counselling Referral Form

Client's Demographic Information

Medical Information

Family Contact Information

Additional Family Contact Information

Referral Source