Self Referral for Volunteer Support
Companioning Community Care …offering support for people with life limiting illness, or disabilities and for people who are grieving.
Date: April 25th, 2019
Name: *
Title
First
Last
Initial
Age:
Gender:
Male Female
Email: *
Email Confirmation: *
Address: *
Street
City
Postal Code
Phone
Caregiver (if appropriate):
First Name
Last Name
Phone
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
yyyy/mm/dd
Life Limiting Illness
Caring for a loved one with a life limiting illness
Bereavement
Disability
3. Which of the following programs are of interest to you:
Relaxation Program
Volunteer Visits
Bereavement Support Group
Bereavement Walking Group
Telephone Companion Calls
Social and Educational Opportunities
Recording Life Stories
Not sure
Other     Please specify
4. Please identify how you hope to benefit from Companioning Community Care support:
Comfort
Companionship
Connection with others
Enable to remain in own home longer
Enhance quality of life
Exercise
Experience caring & acceptance
Increase independence
Improve wellbeing
Opportunity to give & receive support
Participate in a group
Preserve sense of dignity
Reduce isolation
Respite for caregivers
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:
Title
First
Last
Phone
Relationship

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