Secure Portal - Hospice Volunteers of Hancock County

HVHC Volunteer Patient Referral Form

"*" indicates required fields

Patient Demographics

Patient Name*

First Last

Phone*

Address*

Street Address City State ZIP

Directions to house

Specifics to help assist volunteers

Eligibility

Age*

Date of Birth*

Gender Identity*

Service currently received*

Medical Hospice

Palliative Care

Neither Palliative or Medical Hospice

If not on a medical hospice or palliative care program, answer the following three questions.

1. Have you/the patient been hospitalized in the past six months?

Yes

No

If yes, how many admissions have there been?

2. Have there been any changes in how much you’re able to do day to day?

Yes

No

If yes, what changes have you experienced?

3. Has there been noticeable or unintentional weight loss or significant decrease in appetite?

Yes

No

If yes, what have you noticed?

Clothes fitting looser, pounds lost, changes in eating habits, etc.

Name of Medical Palliative or Hospice Organization*

If neither list N/A

Palliative, Hospice, or Life Limiting Diagnosis*

DNR?*

Yes

No

Unsure

POLST Form?*

Yes

No

Unsure

Medical Limitations

Uses walker/cane

Wheelchair

Bedbound

Hearing Impaired

Visually Impaired

Cognitively Impaired

Other

If other, please explain.

Spiritual Practice (if identified)

Services

Volunteer Services Requested*

Companionship

Respite

Evensong Singers

Reiki

Life Stories (audio recording)

Pet Therapy

Other

Additional Information

Primary Care Provider

Primary Care Provider and Practice

Caregivers/Contacts

Primary Contact*

First Last

Relationship*

Phone*

In home?*

Yes

No

Additional Caregiver/Contact

Title or Relationship

In home?

Yes

No

Additional Caregiver/Contact

Relationship

In home?

Yes

No

Referral Information

Referring Agency*

If not an agency, enter n/a

Phone*

Referred by:*

Title or Relationship*

Email*