West of 55 - Referral / Intake Form
West of 55 Friends - A Friendly Visiting Program
About You
Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
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December
Month
Please select a day
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Day
Please select a year
2024
2023
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1920
Year
Address
Street Address
Street Address Line 2
City
Province
Postal Code
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Ethnicity
*
Asian – South
Asian - East
Black - Caribbean
Black - African
Black - North American
Do not know
First Nations
Indian Caribbean
Indigenous Aboriginal
Inuit
Latin American
Métis
Middle Eastern
Mixed Heritage
Prefer Not to Answer
White European
White North American
Other
Language
*
English
French
Mandarin
Cantonese
Punjabi
Tagalog
Spanish
Arabic
Italian
German
Urdu
Portuguese
Other
Your preferred language
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Relationship
*
What is the relationship of your emergency contact to you (spouse, partner, son, daughter, friend, etc.)?
Living Arrangements
Living Arrangement
*
Live Alone
With Spouse / Partner
With Family / Friend
Widowed
Assisted Living
Hospital
Other
Do you have access to the Internet?
*
Yes
No
Ways you have access to the Internet?
*
Computer or Laptop
iPad or Tablet
Smartphone
Other
Do you have any pets?
*
Yes
No
Are you a smoker?
*
Yes
No
Do you use any other in-home services?
*
Personal Support Worker (PSW)
Nursing Services
Physiotherapy
Occupational Therapist
No
Other
Medical Information / Concerns
Medical Information
Please provide us with any medical information that would help us find you the best programs & support.
Health Concerns
Please tell us about any health concerns you may have.
Mobility
*
No
Other
Vision Impairment
*
No
Other
Hearing Impairment
No
Other
Speech Impairment
*
No
Other
Please list any allergies that require regular treatment and medication:
Seniors On the Go
This is to be completed if you, or the person acting as the Substitute Decision Maker (SDM), if you wish to use Re-Imagine Ontario's SeniorsOnTheGo service.
Do you want to use the Seniors On the Go service?
Yes
No
Perhaps in the future
Please explain why you need this service
Example: number of times per week or per month, current difficulties with transportation arrangements, where you need to be transported, etc.
Your Income Situation
Facing financial difficulties
Unsure if I would qualify for this service
Unable to use other transportation services
Other
Authorization
Are you completing this form for yourself or are as a Substitute Decision Maker (SDM)?
*
Myself
SDM on behalf of client
SDM has provided consent for referral to Re-Imagine Ontario?
Yes
No
Referee's Name
First Name
Last Name
Referee's Title
Referring Organization's Name
Referee's Email
example@example.com
Referee's Phone Number
-
Area Code
Phone Number
Today's Date
*
-
Year
-
Month
Day
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Submit
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