Access Clean Referral Form
Community Program by Minor Detail
1. Client Details
Full Name
Address
Phone/Email
2. Service Pathway (Select One)
Service Pathway
Pathway 1 - Fully Supported Care (No Fee) (For those experiencing significant financial hardship or urgent need)
Pathway 2 - Supported Care ($50/hr, Team of 2) (For those needing support at a reduced, more affordable rate)
Pathway 3 - Standard Care ($80/hr, Team of 2) (For those able to pay standard rates and support the program)
Priority Care (Urgent Request) (For time-sensitive situations such as hospital discharge or safety concerns)
3. Communication & Care Reports
Authorized Contact Name
Relation
Email
example@example.com
4. Government-Funded In-Home Services
Is the client receiving publicly funded in-home care?
Yes
No
Program/Provider
I consent to Access Clean using this information for HST exemption purposes
5. Consent to Release Information
I authorize Access Clean to:
Communicate with the referral source
Share care updates with authorized contacts
Store information for service and eligibility purposes
6. Signature (Digital Signature)
Signature
7. Date
-
Month
-
Day
Year
Date
8. Submit Referral
Preview PDF
Submit
Should be Empty: