• Social Prescribing Self-Referral Form

  • SELF-REFERRAL GUIDE

    What is the Social Prescribing Service?

    Social Prescribing is for adults aged 60+ who are living in the Cowichan Valley. It is designed for individuals who are self-motivated but could use support connecting with community resources. 

    Participants work with a Community Connector to identify goals, develop a wellness plan, and connect to programs, services, and activities that support their health and well-being. The Social Prescribing Program is a preventative service that helps older adults maintain their independence and stay connected to their community. 

    Participants should range between 1-4 on the Clinical Frailty Scale. 

    For more information about the Clinical Frailty Scale, please visit: https://bc.healthyagingcore.ca/resources/resource-clinical-frailty-scale-1

    This includes people who are: 

    • Active, motivated, and energetic. They exercise regularly and are among the fittest for their age. 

    • Living without active disease symptoms but are less fit. They exercise and are active occasionally, such as seasonally. 

    • Living with well-controlled medical conditions but are not regularly active beyond routine walking. 

    • Not dependent on others for daily help, but their activities may be limited. They commonly feel slowed down or tired during the day. 

      Eligibility Criteria 

      Adults aged 60+ living in the Cowichan Region who are experiencing:

    • Social isolation or loneliness 
    • Worries about food security 
    • Sadness that makes it difficult to stay connected
    • Life-changing events such as retirement, bereavement, or health decline 
    • A feeling of lost independence 
    • Difficulty making healthy lifestyle choices 
    • Limited access to physical activity 
    • Fatigue or stress related to being a caregiver or receiving care 

      Social Prescribing Is Not Intended For Adults Who: 

    • Are under the age of 60 
    • Fall within the 5-9 range on the Clinical Frailty Scale 
    • Require daily medical services 
    • Do not have a desire to engage in a wellness plan 
    • Do not wish to work toward greater independence 

      The Community Connector is available to provide ongoing support, encouragement, and connection to community resources. Active participant engagement is essential to achieving wellness goals. 

      Before You Apply: 

      Social Prescribing works best for individuals who are ready to take an active role in improving their well-being and connecting with their community. If you feel this program is a good fit for you, please complete the self-referral form below. 

    __________________________________________________________________

     

  • Format: (000) 000-0000.

  • Eligibility for this program begins at age 60.

    ID is required at assessment.

    You are welcome to reapply once you meet the age requirement."

  • Preferred way to contact referrer:

  • Inclusion Criteria

    *Please answer Yes or No for each question below. All questions are mandatory. 


  • I would consider myself as Level 1 to 4 on the Clinical Frailty Scale (see Referral Guide)?*
  • I am interested and motivated to take an active role in improving my health and well-being?*
  • I will be able to independently engage with community resources once connected?*

  • *Unfortunately, you are not currently eligible for the Social Prescribing Program.

    If your circumstances change in the future, please feel free to apply again.

    Community Health Services with Island Health offers a wide range of supports for older adults which may be of assistance to you. For more information, please call 1-877-734-4101 (toll-free).

  • Type of Service Needed*
  • Thank you for your referral. The Community Connector will be in touch soon via your identified preferred method of contact. 
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