Caregiver Referrals

To make a referral for our caregiver support services, please complete the following form.

PLEASE NOTE: There is currently a waitlist for our support services. We will do our best to contact all new referrals by the end of April 2026. Please let us know if your referral is urgent and requires a priority response on the waitlist.

We look forward to connecting with you as soon as possible.

Referral Form

Referral From *

• Self-Referral (I am a caregiver)
• Island Health
• Family Member / Friend / Another Caregiver
• Community Agency
• Other

Island Health Referral Details *

• Family Doctor / Nurse Practicioner
• Geriatric Specialty Services (GSS)
• Long Term Care Case Manager
• PCN Social Worker
• Home Care Nursing
• Adult Day Program (ADP)
• Other

Name of Community Agency *

Name of Island Health Department, Role, etc *

by Date How

Contact Name of person making the referral *

First

Last

Contact Person's email address *

Contact Person's phone number *

Urgency of referral *

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10

Please choose a number between 1 and 10 representing the level of urgency of this referral, with 1 being the lowest urgency and 10 being the highest urgency.

Caregiver Information

Has this Caregiver been referred to our services before? *

• Yes
• No / Not Sure

Name of Caregiver *

First

Last

Caregiver email address

Caregiver phone number *

Where does the Caregiver live? *

• Duncan
• Ladysmith / Chemainus / Saltair / Crofton
• Mill Bay / Cobble Hill / Shawnigan Lake / Malahat
• Cowichan Bay / Cowichan Station / Glenora
• Other

Please note that to be eligible for our services, either the Caregiver OR the person receiving care must live in the Cowichan Valley.

Age of Caregiver *

• 25 or under
• 25-39
• 40-54
• 55-64
• 65-74
• 75-84
• 85 and over

Care Recipient Information

Who is the Caregiver caring for? *

• Spouse/Partner
• Parent
• Adult Child
• Another Family Member
• Friend / Neighbour / Other

Diagnosis (if known)

How many years do you feel that you have been in this caregiving role?

• 1-2 years
• 3-5 years
• 6-10 years
• More than 10 years

Additional details (Please include any information that will help us to best support the Caregiver: caregiving situation, health challenges, etc.) *

Please provide as much detail as possible for why you marked this referral as urgent. *

How did you hear about our services?

The Caregiver consents to be contacted by Cowichan Family Caregivers Support Society. *

• Yes

Submit