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 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: 230 to confirm your referral was received.

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.

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

1: Bereavement Support

2: Hospice Counselling

1: Bereavement Support

Referral Information

Is this an Urgent Referral (If identified as urgent, referral will be followed up within 2 business days)?

Yes No

Name

Organization

Phone

Contact Information

Name of bereaved person

Gender

Female Male Trans Other

I identify as:

Date of Birth

Street Address

Apt #

City

Postal Code

Primary Phone #

Alternative Phone #

Email Address

Preferred language

Reason for Referral:

Name of deceased

Relation to bereaved person

Date of death

Cause of death:

If you are looking for bereavement support for yourself, please continue and complete the questions below; are you interested in…

(Select all that apply)

1:1 Bereavement Volunteer Support 8-week Closed Bereavement Support Groups Grief Chat Circles Social Walking Groups Group Debriefs for Community Partners Complementary Therapies Nutrition Programs Meditation Vibrational Sound Healing Information and referral to other programs

How are you currently coping with grief?

Are there other grief support services that you have used?

Do you feel at risk for self-harm?

Is there any information you would like to share that may help us determine how we may help you?

When you’re ready, please submit this form by clicking the button below:

NOTE: Do not close this window/tab or refresh until you see the message that your request has been submitted.

2: Hospice Counselling

Select one:

Referral Consult

Is this an Urgent Referral (If identified as urgent, referral will be followed up within 2 business days)?

Yes No

Intersection:

Client Name:

Gender

Male Female Trans Other

I identify as:

Street

Apt #

City

Postal Code

Phone #

Cell #

Birth Date

Age

Marital Status

Single Married Divorced Widowed Common Law

Preferred Language

Email (Client)

Health Card #

Primary Hospital

Physicians

PPS%

1: NEXT OF KIN INFORMATION

NOK ID#

Name

Relationship

Home Phone #

Cell Phone #

Work Phone #

Address (if different from client(‘s)

2: NEXT OF KIN INFORMATION

NOK ID#

Name

Relationship

Home Phone #

Cell Phone #

Work Phone #

Address (if different from client(‘s)

Person to contact to discuss hospice

Diagnosis

Anticipated prognosis

<1 month <3 months <6 months <12 months Uncertain

DNR

Yes No

Patient aware of diagnosis

Yes No

Patient aware of prognosis

Yes No Does not wish to know

Family aware of diagnosis

Yes No

Family aware of prognosis

Yes No Does not wish to know

Have end-of-life issues been discussed with patient

Yes No

Reason for referral

Information/Education Wellness Programs (includes comp therapy) Psychosocial Support Spiritual Support Caregiver Support Future Bereavement HUUG (Children’s Program) Other (explain below)

Other

Urgency of response

Within 2 days Within 1 week Within 2 weeks

Referral made to

LHIN IAH DLH Tor Grace Bethell

LHIN Care Coordinator

Support Services

Nursing PSW OT/PT Social Work

Other information

Referral Source

Name

Organization

Trillium CVH BCH IAH LHIN-CW LHIN-MH Other

Phone

Email (a copy of form will be sent to this address)

When you’re ready, please submit this form by clicking the button below:

NOTE: Do not close this window/tab or refresh until you see the message that your request has been submitted.

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

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

First Name

Your best email address

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
info@hearthousehospice.com
Fax 1: 289-724-0620 (electronic fax)
Fax 2: 905-712-4029
Hospice Palliative Care Helpline: 905-667-1865
Charitable Registration Number: 132155011 RR 0001

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