Request Service

Client Profile (Receiver):


Mr.Mrs.Miss.Ms.







Primary Caregiver Information (if applicable):


WorksRetiredAt Home






Client Information:

   

CE-LHINCommunity Support AgencyFamily/FriendPhysicianGAIN ClinicHospitalLong-Term CareODSPOntario WorksSelfSocial MediaVeterans AffairsOther

Private Home / Apt.Rented Room/Group HomeAssisted Living /Supportive Housing

AloneWith Spouse/Partner onlyWith Child onlyWith Parent/GuardianWith SiblingsWith Other RelativesWith Non RelativesWith Spouse/Partner and Child


Services Required:*

Adult Day ProgramAssistance Home from the Hospital (HAL – PSW Support)Assisted Transportation (APC – PWS Support)Assisted Living or Supportive Housing (PSW Support)COPE Mental Health Support Groups (Social Support)Exercise ClassesFalls Prevention ClassesFoot CareFriendly Visiting (Social Support)Home Help (Light Housekeeping)Home Maintenance (Yard Work)In-Home Respite (PSW Support)LEAP (PSW Support)Luncheon OutMeals on WheelsTelephone Reassurance (Social Support)Transportation