Toronto Central area

This form is to be used for completion of the assessment required under the Fixing Long-Term Care Act, 2021 when a person applies for a determination of eligibility for long-term care home admission. The required assessment is of the applicant’s physical and mental health, and the applicant’s requirements for medical treatment and health care. This assessment must be made by a physician or registered nurse.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

Veuillez suivre ces instructions (S’ouvre dans un nouvel onglet)
pour accéder au formulaire.

Formulaire fourni par le ministère des Soins de longue durée en vertu de la Loi de 2021 sur le redressement des soins de longue durée.

Si vous souhaitez être admis dans un foyer de soins de longue durée (SLD), vous devez remplir ce formulaire. Ces renseignements sont requis par Santé à domicile Ontario, le coordonnateur du placement désigné pour les foyers de SLD, afin de déterminer si vous êtes admissible à l’admission. Santé à domicile Ontario peut recueillir d’autres renseignements personnels sur la santé auprès de vos fournisseurs de soins de santé afin de déterminer votre admissibilité. Santé à domicile Ontario peut également utiliser et divulguer les renseignements aux mêmes fins.
Renseignements sur le demandeur

Important Note: Please follow these instructions (opens in a new tab) to access the form.

Form provided by the Ministry of Long-Term Care under the Fixing Long-Term Care Act, 2021.

If you wish to be admitted to a long-term care (LTC) home, you must fill out this form. This information is required by Ontario Health atHome, the designated placement co-ordinator for LTC homes, to determine if you are eligible for admission. Ontario Health atHome may collect additional personal health information from your health care providers
for the purpose of determining your eligibility. Ontario Health atHome may also use and disclose the information for the same purpose.

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

Request for Release of Personal Health Information under the Personal Health Information Protection Act, 2004

• Form to be completed by Ontario Health atHome Care Coordinator and/or Nurse.
• Nursing services must be in place and Nursing Agency/Service Provider Organization must be aware of request and agree to support pronouncement and E.D.I.T.H. protocol.

Your submission of this form will be taken to explicitly mean that you have gained appropriate permission for release of the information contained to the agencies and services to whom you are submitting this. Please also include your Organization’s Release of Information Form, if applicable.

The Palliative Care Common Referral Form (PC-CRF) has been in use by palliative care organizations across the City of Toronto since 2004. The PC-CRF was originally developed by the Toronto In-Patient Palliative Care subcommittee of the Toronto Palliative Care Network (now known as the Toronto Central Palliative Care Network) in order to standardize the application process to access palliative care services throughout the city.

Referral Form for Ontario Health atHome

Telehomecare COPD and Heart Failure Referral Form

Formulaire de renvoi pour le programme d’infirmières et d’infirmiers en santé mentale et en toxicomanie – Viamonde

Mental Health and Addictions Nursing Program referral form – Viamonde School Board

Mental Health and Addiction Nursing (MHAN) Program referral form – Toronto District School Board

Mental Health and Addiction Nursing (MHAN) Program referral form – Toronto Catholic District School Board

Formulaire de renvoi pour le programme d’infirmières et d’infirmiers en santé mentale et en toxicomanie pour le conseil scolaire catholique MonAvenir

Mental Health and Addictions Nursing program referrals from hospitals

Referral form for administering COVID-19 antivirals in Toronto Central community nursing clinics.

Centralized Intake and Referral Application to Specialty Hospitals for the Toronto Central area

Behavioural Supports Outreach Programs (BSOT) general referral form for Toronto Central

Adult Speech Language Pathology Referral Form