Partners in Community Nursing Service Request Form

Partners in Community Nursing Service Request Form

At Partners in Community Nursing, we know every family's and individual's needs are unique. Whether you’re looking for short-term support, ongoing care, or specialized nursing for yourself, your child or loved one, our team is here to listen, guide, and match you with the right services. From in-home visits to flexible shift nursing, we bring expert care right to your door across Durham Region. Let’s start by learning a little more about your situation so we can provide the best support possible.
Name of Primary Contact*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address (within Durham Region):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Care Needs
Who requires nursing care?*

ChildAdultOther
What type of support are you looking for?*

Visiting Nurse (short visits for wound care, IV therapy, palliative support, etc.)Shift Nurse (3–12 hour continuous care at home or school)Not sure yet – I’d like guidance
What service are you interested in?*

Continence CareFoot careGerontological NursingHealth TeachingIntravenous (IV) TherapyOncology NursingOstomy CarePalliative CarePediatric NursingPost-Operative Surgical CareShift NursingWound Care
Current Situation
What’s the main reason you’re seeking care right now?*
Scheduling & Availability
Do you need care during:*

DaysEveningsNightsWeekends
How soon would you like services to begin?*
Family & Support Network
Who else is involved in caregiving at home (family, friends, other agencies)?Type a question*
Are there cultural, language, or personal preferences we should know about?*
Is there anything else you’d like us to understand about your loved one or your family’s needs?*
Funding & Insurance
How do you plan to fund your care with us?*

I’ve been referred or am applying through Ontario Health at Home (OHaH)I have private insurance coverageI will be paying privately (self-funded)I’m not sure yet – I’d like to discuss funding options with PICN
PICN
How did you hear about PICN*

Google/Internet SearchChatGPT/Ai SearchLinkedInFacebookWord of MouthOther
Should be Empty:

Partners in Community Nursing Service Request Form

Care Needs

Current Situation

Scheduling & Availability

Family & Support Network

Funding & Insurance

PICN