REQUEST FOR SERVICES | Salt Spring Hospice Society

Request for Hospice Support

Please complete the form below with information about the patient and their current situation so we can determine how to best support them. These services are offered to eligible* individuals residing on Salt Spring Island.

Who are you requesting services for?

Myself

Client/patient

Family/ Friend

Other

Name of Person Completing Request:

Title or Relationship to Client:

Phone

Name of Client Needing Support:

First name

Last name

Birthday

Year

Month

Day

Phone

Care Home or Home Address:

Primary Contact (If different from above):

First and Last Name

Relationship to Client:

Phone

What type of support are you requesting for the client?

If other, please explain in detail:

Please describe anything we need to know about the client, in order to find the right fit with a volunteer

*Eligible individuals include one or more of the following: diagnosis of life-limiting illness, end stage of life, bereaved individual or anticipatory grief, and/or resident of Lady Minto Extended Care Unit.

Thank you for connecting with me today and giving me peace and better closure. What a great ending for mom. I couldn't have asked for a better hospice person to come to Mom, I felt it when you walked in her room. The only reason I felt ok leaving her.

J. Rush

Request for Hospice Support

Subscribe Form