If you or someone you know is in need of help from Heart House, please complete the form below. ​ Please provide as much information as you are able. 

Once you hit the SUBMIT REFERRAL FORM button the form will be emailed to our secure and confidential email.You should receive a copy of the referral form to the email address you identified in the referee section. If you do not receive an email, please call 905-712-8119 ext: 255 to confirm your referral was received.

Or you can download and print the form and submit it to us by fax at 289-724-0620 or by email: intake@hearthousehospice.com.

We have TWO options below, please complete the form that is most related to your needs: