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:

Referral Information



Contact Information

Reason for Referral:

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

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.


1: NEXT OF KIN INFORMATION

2: NEXT OF KIN INFORMATION





Referral Source

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.