HUUG Palliative Referral

HUUG Palliative Referral Form

For children and youth under the age of 18, who have a significant person in their life diagnosed with a life limiting illness
Demographic Information About the Child/Youth being Referred
Referral Date*

MonthDayYear
Name*

First NameLast Name
Gender*
Address*

Address

Address Line 2

CityProvince

Postal Code
Date of Birth

MonthDayYear
Age*
Primary Language
Secondary Language
Child/Youth Relationship to the Indivdiual Receiving Palliative Supports*
Is the Child/Youth Aware of the Diagnosis?*
Is the Child/Youth Aware of the Prognosis?*
MotherFatherGrandparentSiblingOther Family MemberOther
Additional Children
If referring more than 1 child from the same family, add First Name, Last Name, Date of Birth and Gender in this section.
Reason for Referral and Additional Information
Information About the Individual Receiving Palliative Supports
First and Last Name*

First Name (Individual Receiving Palliative Supports)Last Name (Indiviudal Receiving Palliative Supports)
Gender*
of Indiviudal Receiving Palliative Supports
Individuals Relationship to the Child/Youth*
Relationship of the individual receiving palliative services to the child/youth
CancerOrgan FailureNeurodegenerative DiseaseFrailty/Dementia/Multi-MorbidityOther (Specify in Additional Info Field Above)
Parent/Guardian Information
Name*

First Name (Parent/Guardian)Last Name (Parent/Guardian)
Gender*
(Parent/Guardian)
Parent /Guardian Relationship to the Child/Youth*
Relationship of the Parent/Guardian to the Child/Youth
Contact Number*
Please enter a valid phone number.Format: 000-000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: 000-000-0000.
Email Address
(Parent/Guardian)
Address - complete if different from above

Street Address

Street Address Line 2

CityState / Province

Postal Code
Primary Language
(Parent/Guardian)
Secondary Language
(Parent/Guardian)
Relevant family/custodial information
School Information
Is the school aware of the illness?
School Name
School Location
Referral Source
Referral Submitted by*
First Name Last Name
Referring Organization
Other:
Organization name if not listed above
Referral Contact Number*
Please enter a valid phone number.Format: 000-000-0000.
Referral Email
example@example.com
Should be Empty:

HUUG Palliative Referral Form

Demographic Information About the Child/Youth being Referred

Information About the Individual Receiving Palliative Supports

Parent/Guardian Information

School Information

Referral Source