To contact your local Community Connector, please choose from your geographical area:*
—Please choose an option—Salmon Arm/Sicamous/MalakwaEnderby/Surrounding areasSouth Shuswap/North Shuswap/Chase
Name/Title:
Referral Source:* —Please choose an option—Eagle Valley Community Support SocietyCommunity Based AgencyPhysicianAllied Health ProfessionalNurseHome Health NurseHospital (Registered Nurse)Hospital (Social Work)Family/FriendSelf ReferralOther
Phone:*
Email:*
Name*
Phone*
Email
Address:*
Family Doctor
Date of Birth or Age:*
PHN - Personal Health Number (if known)
Social Engagement
i.e. social groups, community activities, coffee clubs, special events, volunteer programs, vocational opportunities, support groups, education sessions, friendly visits/calls
Physical Activity
i.e. fitness classes, walking groups, chair yoga, lawn bowling, aquafit, sports
Nutrition/Food Programs
i.e. connect with local food banks, farmers markets, food programs; delivery options for groceries and meals
Caregiver Programs
i.e. support groups, education sessions, one-to-one support
Other/Notes:
Home HealthSeniors Outpatient ClinicMental HealthOther
Additional Participant Information:
i.e. discharge date, hearing and visual loss, mobility restrictions, primary language, family contact info, safety concerns, substance use, etc.
Timeline:* NeverAs NeededEvery 6 weeks
Specific Follow-up Requests:
The Participant understands and consents to be contacted by a local Community Connector about their Social Prescribing Program.
Consent* Verbal Consent Received.
Date*
