Waterloo Wellington area

Request for Hospice Palliative Care Services – Form 031B, Completed by a Primary Care Physician

Formulaire de demande pour la divulgation de renseignements personnels. En vertu de la Loi de 2004 sur la protection des renseignements personnels sur la santé Veuillez

Completed by a Primary Care Physician

Ontario Health atHome Child and Youth Mental Health & Addictions Nursing Program
Fax: 1 (519) 571-3957
A mental health nurse will connect with student, parent and/or guardian to confirm consent and finalize eligibility.

FAX COMPLETED FORM TO Ontario Health atHome: 519-742-0635
How is Crisis defined?
A patient is considered to be “In Crisis” if:
1. Patient and/or caregiver safety is at risk and/or there is a risk that a significant health event and/or challenging end-of-life symptoms cannot be managed in their current setting
2. Patient at risk of requiring ED or acute care admission
3. Community resources have been exhausted and family/ caregivers are unable to cope with the patient’s care needs
4. There is a risk that the services required to meet the patient’s end-of-life care plan goals may not be available in their current setting
5. Patient at risk of not accessing their preferred place of death (considering recent trajectory of the PPS score).

Acute Care to Rehab & Complex Continuing Care (CCC) Referral
Fax Completed Form to 519-742-0635

Completed by Primary care Physician to request Home Care services. Patient/Families may also print this referral form to bring to an appointment for completion.
If initiating referral for HPC services, please use Form 031B, “Request for Hospice Palliative Care Services”

Completed by Retirement Home staff when requesting a Swallowing Assessment