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Smiths Falls
613-283-6745
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Home
About Us
Careers
Services
Client Referral Form
Meals on Wheels
Assisted Transportation
Footcare
Congregate Dining
Home Help/Home Maintenance
Respite
Volunteer Hospice Visiting Service
Grief & Bereavement
Volunteer
Events
News
Contact
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Client Referral Form
Surname
First
Middle
Address
Tel #
Alternate Contact Person
Speak with
Client
Alternate Contact
Alternate Phone
Relation to Client
Date of birth (mm-dd-yyyy)
Health Card #
Physician
Physician #
Is client/caregiver aware of referral?
Yes
No
Health Information/Diagnosis:
Is Palliative care status confirmed?
Yes
No
Is there a Home DNR-C?
Yes
No
Services currently in place
Reason for referral
Services Required
Meals on Wheels
Transportation
Diners Club
Footcare (Clinic Only)
In-Home Respite
Volunteer Hospice Visiting Service
Home Help
Referral Information
Physician
FHT
CHC
ED
Inpatient
Other
Reason for admission to hospital
Additional Information & Client’s Primary Goal
Referral Source Name
Tel #
Date
Submit
Join us for CHSLC's very first annual Barn Dance Fundraiser! We’re super excited to celebrate with you, so don’t forget to reach out to the office for tickets and all the fun details about this fantastic event!
