Client Referral Form

Please take time to fill this form out as completely as possible before pressing SUBMIT. Once submitted, this information will be reviewed by the team at Shuswap Hospice and someone will reach out to you as soon as possible.

Referring Agency *

(hospital, care facility, agency, self)

Name of person making the referral *

(from agency above)

Phone *

Email *

Email

Confirm Email

Client's Name *

First

Last

Client's Family Physician

(from agency above)

Client's Email Address *

Email

Confirm Email

Click to confirm we can add this email address to our email list, receiving periodic updates about our programming and events.

• Yes
• No

NOTE: You can unsubscribe at any time.

Client's Phone Number

Is it okay to leave a message?

• Yes
• No

Client's Address

Client's age

Present Location

(include room number, if applicable)

Diagnosis

VAX status

Faith/Belief

Comment or Message

Referral Type *

• Palliative
• Grief
• Companion
• Children and Youth
• Nav-Care

Is the Client aware of the referral? *

• YES (type name in box below to confirm)
• NO

Client Signature:

Is the family aware of the referral? *

• YES
• NO

Signature of parent or guardian if child is under 18 years of age.

Primary Support Person *

First

Last

Relationship

Support Person's phone number

Submit

Please notify the Hospice Society upon the death or relocation of the above individual.