Intake - Catholic Family Services of Hamilton

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Programs
Counselling
Join Our Team
About
Contact

Programs

Seniors Programs - Referral form (intake)

Abuse/Intervention Telephone Support Diogenes/Gatekeepers Dementia

Date:

Referral agency:

Phone#/Ext.

Surname:

First Name:

Address:

City / PC:

Phone#:

Male Female

Date of Birth (mth/day/year):

Health Card #:

Preferred Language:

Does this client require services in French:

Yes No

Living Arrangements:

Contacts / Family / Power of Attorney (if known):

Presenting Issues:

Recommended Intervention:

Any Suspected Abuse:

Is client aware of/in agreement with the referral:

Yes No

Smoker:

Yes No

Pets:

Yes No

If yes, what kind:

Infectious Diseases:

Yes No

If yes, what kind:

Infestation of home:

Yes No

If yes, what kind:

Safety concerns for staff:

Physical Functioning (mobility, aids, chronic conditions):

Cognitive Functioning:

Social Functioning:

Diagnosis (if available):

List services presently involved with Client (days of week, time of day):

Additional information that may be useful to provide service for client:

Unfortunately, we do not have the resources to alleviate bed bug infestations; however, we offer consultations with community partners to access appropriate services.

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CFSHW Referral Form

Your Field Value

Contact info

To make a referral to a Seniors program, use this referral form:

Or contact our Intake office at
905-527-3823 Ext. 279

intake@cfshw.com

Seniors at Risk

Living with Dementia

Senior Peer Volunteers

Catholic Family
Services Of Hamilton

is a well respected, values driven social services agency that works with a range of clients providing counselling, community connection, and education programs.

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