Caregiver Referrals - Cowichan Family Caregivers Support Society

Referral Form

Referral From *

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

Island Health Referral Details *

Name of Community Agency *

Name of Island Health Department, Role, etc *

Contact Name of person making the referral *

First

Last

Urgency of referral *

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 phone number *

Missing Contact Info

Caregiver does not have an email address

Caregiver email address *

Caregiver's Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Age of Caregiver *

Care Recipient Information

Who is the Caregiver caring for? *

Diagnosis why detail

What is the Care Recipent's diagnosis? *

Known Diagnosis
Unknown Diagnosis

Name of Diagnosis *

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