Self Referral for Senior + Caregiver Support

Caregiver (if appropriate):


1. Which language(s) do you speak:
English
Farsi
French
Korean
Tagalog
Other    


2. Nature of Support you are requesting: *
Palliative care for myself    Date accepted into BC Palliative Care Program
Life limiting illness or chronic illness
Caring for a loved one with a life limiting illness or chronic illness
Bereavement
Disability


3. Which of the following programs are of interest to you:
Relaxation Program
Volunteer Visits
Grief Support Group
Telephone Companion Calls
Walking Companion
Other     Please specify


4. Please identify how you hope to benefit from Senior and Caregiver Support:
Companionship
Connection with others
Enable to remain in own home longer
Enhance quality of life
Exercise
Improve wellbeing
Reduce isolation
Respite for caregivers
Suppport of others who have experienced loss
Tools to deal with my grief
Other     Please specify


5. Please note anything we should know to ensure your safety and well-being, and to assist in matching you with a volunteer. (e.g. special needs, mobility challenges, allergies, infection, etc.)
Emergency Contact:


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