Client Referral Form

To refer a client for our meals on Wheels service please fill out this form. We will then contact you by phone to follow-up on your referral. It usually takes us up to 2 or 3 weeks to treat a referral and the call takes around 10 minutes. Filling up a referral doe not ensure that we will be able to provide the service to the client and we do not take waiting list. Note that it may take 1-2 weeks to receive a reply to a referral, and that submitting a referral do not guarantee access to our service. Please call 514-284-9335 for any questions. Thank you!

General Information
Client's Name*
First Last
Client's Gender*
Address*
Street Address Appartment number (if applicable) City Postal Code
Cross Street
Client's Phone Number*
client's email adress (if applicable)
Client's Language of Correspondence*
What is the client's language of correspondence?*
Client's Date of Birth*
MM slash DD slash YYYY
Is it possible to contact the client directly?*
Reason for Referral, please explain.*
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. Explain why you are referring this client to our service.
Would the service be needed for a temporary or indefinite time?*
Please indicate an estimate of the lengh the service might be needed for*
Does the person you are referring leaves alone ?*
We serve clients who live alone and/or are socially isolated. In exceptional circumstances families or couples are considered if everyone is experiencing a loss of mobility and / or autonomy
Does the person you are referring has a caregiver who supports them on a regular basis ?*
You can detail you previous answer here
How many meals would the client need to receive per week?*
As we do not have the capacity to accept all the clients from whom we receive referrals, we prioritize clients who needs to receive meals three times a week or more.
Do the client agrees with this referral and wants to receive a meal on wheels service?*
Does the client have any behavioural problems that may affect a volunteer delivering the meals?*
Please explain the behavioural issues*
Dietary Restrictions
List all of the client's known FOOD ALLERGIES.
Note that we can't accommodate clients with anaphylactic allergies. We can't accommodate for any contact-allergies either.
List all of the client's known food restrictions related to health condition, religious beliefs or cultural reasons.
Note that we take into consideration food restrictions, related to medical condition, religious belief and for cultural reasons but we can't accomodate food dislikes. If the client you are referring has a lot of food restrictions it is possible that we won't be able to accomodate them.
Referral Information
Name of Referring Party*
Note that we will contact you if any issues arise related to the referred client. Feel free to contact us if you have any questions. If you stop being the referring party for the client you are referring, we will ask you to provide us with the contact information of the new healthcare professional caring for the referred client or to let us know if the client is not cared for any longer
First Last
Referring Institution*
e.g. CLSC, Hospital
Tittle of Referring Party*
Please indicate your profession*
Referring Party's Phone Number*
Please include the extension number if applicable.
Referring Party's Email Address*
Emergency Contact
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 Province Postal Code
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, 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, 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, DO NOT fill them out.
First Last
Phone Number of Person Paying for Service
Additional Comments for Reference
Follow-up call about the referral*
Please choose a date and time for a follow-up call about this referral, we will call you at the phone number you indicate below. A follow up call is mandatory in our referral process, it will allow us to ask additional questions we may have and to inform you of where we are at in the process. Also, it is important to note that filling out this form does not guarantee that we will be able to put in place the service for the person you are referring due to our capacity limit.
Phone number for the follow-up call*
Please indicate the phone number where we can reach you for the follow-up call about this referral. If it differs from your office phone number, we will only contact you on this number for this follow-up call.

Client Referral Form

General Information

Dietary Restrictions

Referral Information

Emergency Contact

Billing

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