Referral Form

Client Referral Form
Referrer

First NameLast Name
Organization (if applicable)
Phone Number*
Email Address*
example@example.com
Relationship to Client:*

FamilyFriendHealthcare ProviderOther
Client’s Full Name

First NameLast Name
Address*

Street Address

Street Address Line 2

ParishState

Postal Code
Date of Birth*

MonthDayYear
Date
Phone Number*
Email Address if available
example@example.com
Is the Client aware of this referral? *
Services Needed*

Personal Care (Bathing, Dressing, GroomingCompanionshipTransportationMeal DeliveryHousekeepingLive-In CareMedical SupportSubscription PlanRespite CareOther
Section 4 Additional Notes or Special Considerations
MonthDayYear
Date
Please verify that you are human*
Privacy & Confidentiality Statement

Caring Hearts Bermuda is committed to protecting your privacy. The information you provide will be used only for assessing and delivering our services, and will be kept strictly confidential. We will not share your details with third parties without your consent, except where required by law or to coordinate care with authorized service partners. All records are stored securely and accessed only by authorized personnel. By submitting this form, you consent to our collection, use, and storage of your information in line with our Privacy Policy.
“Your information will be kept strictly confidential and used only for care coordination and service delivery.”
How Our Referral Program Works
We truly appreciate your referral to Caring Hearts Bermuda - thank you for thinking of us! Here's what to do and expect:
Who can refer?
- Current Clients
- Family members of clients
- Caregivers and staff
Who Can Be Referred?
- New clients who:
  - Are not already in the Caring Hearts Bermuda database
They Sign Up for Care
- Once the referred person signs up and completes their first full month of paid services, the referral is successful.
You Get Rewarded
- You’ll receive a $50 gift card to say thank you!
Referral Reward

Referrer Type                                              Reward Offered
Clients & Families                 $50 service credit or a wellness care package
Caregivers & Staff                 $75 bonus or equivalent food voucher
Community                            $100 donation to an organization (Dementia Centre, PALS)
Terms & Conditions
- Referred person must not have previously used CHB services.
- Rewards are issued only after the referred client’s first full payment.
- Self-referrals are not allowed.
- Referral credits are non-transferable and must be used within 3 months.
- CHB reserves the right to modify or discontinue the program with notice.
“Let’s care for our community together – one heart at a time”
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