Circle of Care Referral

Comments

This field is for validation purposes and should be left unchanged.

Referral criteria: Individuals can be of any age but must have a life-limiting illness (any age, at any stage).

The Alberta Northwest Palliative Care Society's Circle of Care is a community-based, in-home palliative support program designed to help individuals remain in the comfort of their own residence. Specially trained volunteers are matched for non-medical companionship (friendly visiting), advance care planning, and/or navigation assistance. There is no cost to the individual or family.

How are you submitting this referral?*

Self Referral

Healthcare / Social Services Professional

Family Member / Caregiver

Self Referral

Name

Phone Number

Were you referred to our program?

Yes

Health Care / Social Services Referral Information

Referring Professional Name

Role / Title

Organization / Clinic Name

Address

Phone

Family Member / Caregiver Referral

Relationship to Recipient

Address

Phone

Primary Contact (for scheduling & communication)

Is the care recipient also the primary contact?

If No, please complete the primary contact details below.

Yes

Primary Contact Name

Relationship to Recipient

Phone

Recipient Information

Gender

Male

Female

Other

Pronouns Used

Recipient Name*

First Middle Last

Date of Birth

Address

Municipality

Postal Code

Cell Phone

Home Phone

Reason for Referral

Services Required

Companionship

Advance Care Planning

Navigation Assistance to Other Support Systems

Does the recipient know they have been referred for Circle of Care?

Yes

Recipient Health Info

Mobility

Cognition

Other Agencies Being Used

Special Considerations our volunteer should be aware of

e.g. language preferences, cultural and/or religious needs, special interests

Confirmed Diagnosis(es)

With diagnosis date if possible

Any additional information you would like to provide

~ Circle of Care - Referral Form ~

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