Referral Form - Connection In Action

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Referral Form

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    - How Can I Promote Social Connections in My Community?
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Referral Form

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Complete our online referral form

Complete the form fields below, and our Connection Specialist will be in touch within 1 – 3 business days. If you do not want to use our online form, you can print this form by clicking on the ‘download’ button and fax it to (905) 844-5656. You can also call us at (905) 844-2299.

Client Information

Name(Required)

First Last

Referral Date

DD slash MM slash YYYY

Date of Birth

DD slash MM slash YYYY

Title

Mr.

Mrs.

Ms.

Marital Status

Married

Divorced

Single

Widowed

Address

Street Address City Province Postal Code

Apt

Code

Main Phone

Other Phone

Preferred Language

English

Other

Housing

House

Apartment

None

Other

Preferred language – other text

Preferred Language

Accommodations Required (list)

Best way/time to contact client

Referral Source

Please select one. Are you referring:

From an agency

For myself

For someone I know

Contact Name

First Last

Agency (if applicable)

Email

Phone

Client is in agreement with referral to Connection in Action program and with their personal information being shared?

Yes

No

Additional Relevant Information

Permission to Submit(Required)

Connection in Action is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form.

By checking “I agree” you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online.

Please contact us by telephone at (905) 844-2299 if you do not wish to submit this information online and we will be happy to assist you.

I agree

Email

This field is for validation purposes and should be left unchanged.

Download the Referral Form as a PDF

Download PDF file of our Referral Form

Connection in Action is advised by Halton’s Older Adult Isolation Action Table and is an initiative of Halton’s Community Safety and Well-Being Plan.

Contact Us

Phone: (905) 844-2299
Email: Hello@ConnectionInAction.ca
Twitter: @HaltonCIA
Facebook: @HaltonCIA

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Name

First Last

Role

Older adult

Community member

Service provider

Phone Number

Email Address

Message

Name

This field is for validation purposes and should be left unchanged.

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About Connection in Action

About Social Connections

Get Involved

Complete our online referral form

Client Information

Referral Source