Referral Form - Dorothy Ley Hospice

Bereavement Referral Form

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Bereavement Referral Form

The Dorothy Ley Hospice provides bereavement services to grievers who live in the Etobicoke community. We support family members who live outside of Etobicoke if your loved one was served by the Hospice in residence or in home.

If you do not live in Etobicoke or your loved one was not served by the hospice, you are welcome to call us and we can direct you to grief support services in your area. Call Jennifer at 416.626.0116 x 233

Information about the Bereaved

First Name

Last Name

Phone Number

Date of Birth

Address

Preferred Language

Gender

Male Female

Information about the Individual who is deceased

Name of deceased

Date of death

Cause of death

Relationship to the deceased (eg. I am the spouse, son, daughter, sister, parent … of the deceased)

Was the deceased supported with palliative care by The Dorothy Ley Hospice team?

Yes No

Who is completing this form?

I am completing this form for myself I am a healthcare provider completing this form for a client

Name

Agency

Role

Phone

Confirm that your client has given consent for this referral

If you are looking for grief support for yourself, please fill out the questions below

How are you currently coping with your grief?

Do you have any supports in place at the moment to help you?

Do you feel at risk for self-harm?

Is there anything else you would like to share?

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Bereavement Referral Form

Bereavement Referral Form

Information about the Bereaved

Information about the Individual who is deceased

Who is completing this form?

If you are looking for grief support for yourself, please fill out the questions below

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