Referral Forms

How we help

If you or someone you know is in need of help from Hospice Mississauga, please complete the appropriate form on this page. Please provide as much information as you are able.

Once you hit the SUBMIT button the form will be emailed to our secure and confidential email.You should receive a copy of the referral form to the email address you identified in the referee section. If you do not receive an email, please call 905-712-8119 ext: 224 to confirm your referral was received.

Or you can download and print the form and submit it to us by fax at 289-724-0620 or by email: intake@hospicemississauga.ca

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Referral Information

Is this an Urgent Referral? (If identified as urgent, referral will be followed up within 2 business days)

Name *

Email *

Organization

Phone

Contact Information

Name of bereaved person

Date of Birth

Gender

Female
Male
Trans
Non-Binary
Other
Prefer not to say

I identify as:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone

Email address

Alternate Phone

Preferred Language

Reason for referral

Name of deceased

Relation to bereaved person

Date of death

Cause of death

If you are looking for bereavement support for yourself, please continue and complete the questions below; are you interested in —

Checkboxes

1:1 Bereavement Support
Complementary Therapies
8-Week Closed Bereavement Support Groups
Information and referral to other programs
Grief Chat Circles
Nutrition Programs
Social Walking Groups
Meditation
Group Debriefs for Community Partners
Vibrational Sound Healing

How are you currently coping with grief?

Are there other grief support services that you have used?

Do you feel at risk for self-harm?

Is there any information you would like to share that may help us determine how we may help you?

When you’re ready, please submit this for by clicking the button below

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Client Information

Client Name *

Date of birth *

Gender

Female
Male
Trans
Non-Binary
Other
Prefer not to say

I identify as:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary phone

Cell phone

Marital status

Single
Married
Divorced
Widowed
Common law
Other

Preferred Language

Health card #

Palliative physicians

Email (client) *

Primary Hospital

Client lives:

1: Next of Kin Information

Next of Kin ID#

Full Name

Relationship

Phone

Alt Phone

Address (if different from Client(’s)

2: Next of Kin Information

Next of Kin ID#

Full Name

Relationship

Phone

Alt Phone

Address (if different from Client(’s)

Person to contact to discuss hospice

Client
Next of Kin 1
Next of Kin 2
Other:

If other, please add details here:

Life-limiting conditions

Cancer
Neurodegenerative Disease
Organ failure
Frailty/Dementia/Multi-morbidity
Other:

If other, please add details here:

Diagnosis

PPS

Infectious disease:

If yes, please add details here:

Anticipated prognosis

< 1 month
< 3 months
< 6 months
< 12 months
Uncertain

DNR

Patient aware of diagnosis

Yes
No
Does not wish to know

Patient aware of prognosis

Yes
No
Does not wish to know

Family aware of diagnosis

Yes
No
Does not wish to know

Family aware of prognosis

Yes
No
Does not wish to know

Have end-of-life issues been discussed with the patient

Yes
No
Does not wish to know

Allergies

If yes, please add details here:

Reason for referral

Reason

Counselling
Caregiver support
Information/Education
HUUG (Children’s Program)
Social Connextion (Wellness Program)
Spiritual Support
Other:

If other, please add details here:

Referral Source

Name

TPH
BCH
Bram E.
LHIN-MH
LHIN-CW
Other:

If other, please add details here:

Phone

A copy form will be sent to this address.

Additional information

When you’re ready, please submit this for by clicking the button below

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Referral Source

Is this an Urgent Referral? (If identified as urgent, referral will be followed up within 2 business days) *

Referrer Name *

Phone

Organization

Email Address *

Referrer Profession

Nurse
Physician
Social Worker
Family
Teacher/School
Other

If other, please explain:

Children's Information

1. Full Name

Date of Birth

Relationship to patient

Gender

Female
Male
Trans
Non-Binary
Other
Prefer not to say

I identify as:

Lives with patient

Informed of Diagnosis

Refer for services

Informed of Prognosis

Has their school been notified?

Phone number of school

Name of school

2. Full Name

Date of Birth

Relationship to patient

Gender

Female
Male
Trans
Non-Binary
Other
Prefer not to say

I identify as:

Lives with patient

Informed of Diagnosis

Refer for services

Informed of Prognosis

Has their school been notified?

Phone number of school

Name of school

3. Full Name

Date of Birth

Relationship to patient

Gender

Female
Male
Trans
Non-Binary
Other
Prefer not to say

I identify as:

Lives with patient

Informed of Diagnosis

Refer for services

Informed of Prognosis

Has their school been notified?

Phone number of school

Name of school

4. Full Name

Date of Birth

Relationship to patient

Gender

Female
Male
Trans
Non-Binary
Other
Prefer not to say

I identify as:

Lives with patient

Informed of Diagnosis

Refer for services

Informed of Prognosis

Has their school been notified?

Phone number of school

Name of school

Family Information

Name of Dying/Deceased

Dying or Deceased

Dying
Deceased

Gender

Female
Male
Trans
Non-Binary
Other
Prefer not to say

I identify as:

Relationship with children?

Date of birth

Date of death

Diagnosis

Prognosis or Cause of Death

Guardian/Custodian Information

Name of Guardian/Custodian

Primary Phone Number

Relationship to Children

Alternative Number

Email Address

Primary language

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Other Adults

1. Full Name of Adult

Relationship to children

Lives with child/ren

Informed of prognosis

Informed of diagnosis

2. Full Name of Adult

Relationship to children

Lives with child/ren

Informed of prognosis

Informed of diagnosis

3. Full Name of Adult

Relationship to children

Lives with child/ren

Informed of prognosis

Informed of diagnosis

More Details

Relevant family/custodial info

Relevant religious/cultural practices

Reason for referral

When you’re ready, please submit this for by clicking the button below

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