Home and Community Care
Intake and Linking Referral Form
REFERRAL IS: Urgent Non-Urgent
PATIENT INFORMATION
(Last Name, First Name)
Health Card Number and Version Code: DOB (dd-mmm-yyyy): Gender: Male
Home Address:
Female
City: Postal Code:
Entry Code:
Home Phone: Cell Phone:
CONTACT INFORMATION
Language Spoken/Preferred:
Alternate Contact:
(First Name and Last Name
Patient Knowledge of Referral: No Yes
REFERRAL SOURCE
Name: Relationship:
Phone: Agency:
MEDICAL CONTACT
Physician Name:
Attending Referring GP Other - specify:
Address:
Phone 1: Ext. Phone 2: Ext.
Cell Phone: Fax:
REASON FOR REFERRAL
Reason for the referral/presenting problem/comments:
Health Links Laboratory Long Term Care Placement Nursing
Nutritional Services Occupational Therapy Personal Support (e.g. bathing, dressing) Physiotherapy
Social Work Speech Lanuage Pathology
Community Linking (e.g. housekeeping, shopping, t
Home and Community Care at Central Local Health Integration
Network to mail or email community resources to patient at:
Has the patient been in the ER/hospital within the last 14 days? Unknown No Yes
Does the patient have a current cancer diagnosis? Unknown No Yes
Has the patient had any recent falls within the last 14 days? Unknown No Yes
Has there been a recent change to the patient’s medical condition in the last 14 days? Unknown No Yes
Can the patient manage their medications? Unknown No Yes
Does the patient have any difficulties with bathing, dressing, meals,
appointments, shopping, banking, etc.?
• If “Yes” - specify:
Is anyone assisting the patient? Unknown No Yes
Fax completed form to: Newmarket Office (905) 952-2404 OR Sheppard Office: (416) 222-6517
