Download Referral PDF This form can be completed as a self-referral or by a healthcare professional, family member, caregiver or friend. Referral Information Name of person to receive hospice support: Date of Referral: Age/DOB: Language: email: Phone: Physical Home Address: Current Location of person pick one: Home AddressHospitalLong Term Care FacilityOther Address if different than above: If known: Home Health Nurse: Nurse Phone Number: Physician Name: Physician Phone Number: Referral Source Name and Relationship to person: Phone Number: Email Address: Type of Support Requested Check all that apply: Palliativeend-of-life hospice supportGrief Support Is this person aware of this referral? YesNo If not, please briefly explain why not: Who should we contact regarding this referral? The person directlyThe person making the referralOther If other please provide full name and contact information: Is there any other information you would like to share? Initial here to declare the information provided is accurate & complete Your signature/type your name if submitting electronically Electronic submissions will be directed to the Volunteer Coordinator through the confidential Elk Valley Hospice email account (elkvalleyhospice@gmail.com). This inbox is checked regularly however if this referral is urgent and time-sensitive or contact hasn't been made within 72 hours, please call us at 250-423-4453 ext38109 and our goal is to return your call within 24 hours.
