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. 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 *

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

before? email our

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