Palliative - Heart House Hospice

REFER SOMEONE905-712-8119

1-855 Matheson Blvd E., Mississauga, ON L4W 4L6

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Heart House Hospice

Hospice cares when dying happens

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How We Help
Calendar
Resource Library
Support Us
About Us
In The News

WE ARE HERE. LET US HELP.

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 email to our secure and confidential email and copied to you if you provide an email address under referee section.

Or you can download and print the form and submit it to us by fax at 905-712-4029 or by email: info@hearthousehospice.com.

Referral Date

Referral source

Name

Organization

Other

Phone

Personal Information

First name

Last name

Gender

Street Number

Street Name

Apt #

City

Postal Code

Home Phone Number

Mobile Phone Number

Email Address

Birth Date

Age

Marital Status

Health Card Number

Does The Patient Speak English?

Yes No

If no, what languages do they speak?

Primary Physician

Primary Hospital

Next of Kin (NOK)

First name of NOK

Last name of NOK

Relationship with NOK

NOK Home Phone Number

NOK Mobile Phone Number

NOK Work Phone Number

NOK Email Address

Address - same as above

Yes No

If no, please provide NOK Address below:

NOK Street Number

NOK Street Name

NOK Apt #

NOK City

NOK Postal Code

Diagnosis

Tell us about the diagnosis

Anticipated Prognosis

PPS

Is patient aware of diagnosis?

Is their family aware of diagnosis?

Is patient aware of prognosis?

Is their family aware of prognosis?

Urgency of response?

Is client currently an in patient at hospital?

Reason for referral (check off as many as needed)

Psychosocial support Information/Education Caregiver Support Wellness Programs HUUG (Childrens Programs) Spiritual Care Bereavement Counselling Other

Have end-of-life issues been discussed with the patient?

Referrals to agencies/hospices

IAH DLH Bethell LHIN Other

If other, please explain:

Please add any other details you would like use to be aware of:

If you're ready, please submit this form by clicking the button below:

Download "Having a conversation about dying, death and end of days"

We’ll also send you regular emails about upcoming events.

First Name

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Contact Us

Heart House Hospice
855 Matheson Blvd. East, Unit # 1
Mississauga, Ontario L4W 4L6

Office Hours:
Monday to Friday
8:30 a.m. to 4:30 p.m.

905-712-8119
905-712-4029
info@hearthousehospice.com

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