Client Referral Form

Please note that a referral does not necessarily result in approval and delivery of services. If there is a problem with the referral, the Client Coordinator will contact you directly. Bear in mind that you will be contacted upon the confirmation or rejection of the referral. Thank you!

Today's Date*
Client's Name*
First Last
Client's Gender*
Street Name and Number*
e.g. 111 Roy E.
Apartment Number (if applicable)
e.g. Apt. 14
Entry Code (if applicable)
Cross Street*
Postal Code*
Client's Phone Number*
Client's Date of Birth*
Client's Language of Correspondence*
What is the client's language of correspondence?
Is it possible to contact the client directly?*
Reason for Referral*
Please note that our target population is individuals experiencing a loss of autonomy. Common reasons for loss of autonomy are physical illness, aging, reduced mobility, accident, and cognitive loss. Please explain why you are referring this client to our service.
Does the client have any behavioural problems that may affect a volunteer delivering the meals?*
Please explain the behavioural issues*
Dietary Restrictions: Please list all of the client's known FOOD ALLERGIES.
Please note that we do not take clients with anaphylactic allergies. We cannot accommodate for any contact-allergies either.
Please list all of the client's known FOOD DISLIKES.
Name of Referring Party*
Please note the Roulant is not an intervention service. We will follow-up with you if any issues arise related to the referred client. Feel free to contact us if you have any questions.
First Last
Title of Referring Party*
Referring Institution*
e.g. CLSC, Hospital
Referring Party's Phone Number*
Please include the extension number if applicable.
Referring Party's Email Address*
Name of the Client's Emergency Contact
First Last
Emergency Contact's Relation to Client
e.g. friend, sister, son
Emergency Contact's Phone Number
Emergency Contact's Address
This field is not required, unless the emergency contact will be responsible for the client's billing.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing: Does the client have financial constraints that would inhibit them from paying the default price of 6.00$/meal?
This section is to be filled out to the best of your knowledge. If you do not know the answers, please do not fill out this section.
Does the client manage their own finances?
Who will be responsible for payment?
If it is the above-mentioned emergency contact, please fill out all the fields in the "Emergency Contact's Address" field. If it is a person other than the emergency contact, fill out the following fields to the best of your knowledge. If you do not know the answers to the fields below, please DO NOT fill them out.
First Last
Address of Person Paying for Service
Please fill this out if a third party will pay for the service.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number of Person Paying for Service
Additional Comments for Reference

Client Referral Form

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