If you prefer, you can download and print the form and email the completed document to [email protected].Print Form Indicates required field Referral information referral_left_column Referral date Contact name Email referral_right_column Organization name Contact number Client/SDM approved referral Y N Client information client_left_column Client name DOB Contact number Street address Postal code client_right_column Gender Male Female Email City Language If required: substitute decision maker information sdm_left_column SDM name Alternate number Street address Same as client address Other address Postal code sdm_right_column Day time number Same as client contact number Day time other Email City Preferred language Medical information medical_left_column Primary care physician Phone number medical_right_column Fax number Overall health concerns Overall health concerns: Balance Strength Range of motion Gait/Ambulation Acute Injury/event (sprain, fracture, cardiac, neuro) Post-operative High risk for falls / post fall Pain Needs support with ADLs Fine motor skills Home safety Coughing while eating or taking longer to eat meals Making modification to their foods or avoiding certain foods History of acid reflux Gradual or sudden change in their communication Difficulty understanding what the client is saying (not related to ESL) Difficulty finding their words Chronic conditions Chronic conditions: Alzheimer's/Dementia Asthma Cardiac Diabetes Stroke Other Arthritis Cancer COPD Neurological (ALS, MS, Parkinson's) Shortness of breath Considerations for the program Does the client suffer with incontinence? Yes No Does the client need assistance with toileting? Yes No Does that the client have responsive behaviours? Yes No If the client has responsive behaviours to what level? Does the client have impulsivity? Yes No If the client has impulsive behaviour to what level? Is there any history of violence? Yes No Explain Other concerns
