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SMILE PROGRAM

Name: Phone: Relationship: Caregiver: Call Emergency Contact for...DOE/Admission:...Additional Information...**Health Information/Medical Diagnosis:...What services does client currently receive?
https://www.southeasthealthline.ca/pdfs/SMILE%20Referral%20Form%20-%20Ver.8.pdf

von Belleville and Trenton Stroke Exercise Flyer.pdf

A FREE Exercise Program designed for Stroke Survivors of all abilities and their Caregivers!...Belleville...YMCA of Central East Ontario...Belleville Branch...433 Victoria Ave...Wednesdays &...
https://www.southeasthealthline.ca/pdfs/von%20Belleville%20and%20Trenton%20Stroke%20Exercise%20Flyer.pdf

New Client Application Form - Sept 2023 -FINAL.pdf

If I need help, I use the support of local services/programs If I need help, I don’t know where to go...Are you Pregnant? ...No Yes – Please provide expected due date (yy/mm/dd)> YYYY-MM-DD...Do...
https://www.southeasthealthline.ca/pdfs/New%20Client%20Application%20Form%20-%20Sept%202023%20-FINAL.pdf

CPC Patient Information Sheet

a list of support services in your community. ...You...can learn more about support services in your...community by:...Visiting www.ontario.ca/healthcareoptions...Contacting your Home and...
https://www.southeasthealthline.ca/pdfs/Napanee%20Physiotherapy%20and%20Rehabilitation%20-%20OHIP%20Insured%20Physiotherapy%20Information.pdf

Hulpr Rack Card

accompaniments to support a...wide range of needs....More than just a ride!...Dialysis Treatments...Wheelchair Accessible...Hospital Discharges...Medical Appointments...Scheduled in Advance...At...
https://www.southeasthealthline.ca/pdfs/Hulpr-Brochure-Jan2023.pdf

Centralized Referral Form

Are you interested in meeting/talking with someone from Peer Support? ...Yes No...Are you interested in working with someone to access resources in your community: Yes No...Are you looking only...
https://www.southeasthealthline.ca/pdfs/SCIO-centralized-referral-form.pdf

AMHS-KFLA Fillable Referral Form 2019

Mental Health Support Services...Addiction Support Services...Clinical Counselling...Housing...Vocational...Gambling...Eating Disorder...REFERRAL AGENT INFORMATION...(if other than...
https://www.southeasthealthline.ca/pdfs/amhs-kfla_addictions_mental_health_kingston_referral_form.pdf

CHS-External-Referral-Form-March2021.pdf

CONNECT Mental Health General Support Services...Hearing Care Counselling Settlement Program for Newcomers...Referral for Employment: FAX: 1-855-259-8152 E-MAIL: employmentservices@chs.ca...Job...
https://www.southeasthealthline.ca/pdfs/CHS-External-Referral-Form-March2021.pdf

rac_lbp_patient_intake_form_march_2020.pdf

I have support from people who can assist me with activities in the home, work or community? ...(check one)... Strongly Agree  Agree  Neutral  Disagree  Strongly Disagree...PATIENT INTAKE...
https://www.southeasthealthline.ca/pdfs/rac_lbp_patient_intake_form_march_2020.pdf

“APPLICATION TO REGISTER” For Health Services

Number of people in one household who are supported by this income:___________________...Revised: August 2018 CL Application for Oral Health Program Page 2...HEALTH CARE...Do you have a family...
https://www.southeasthealthline.ca/pdfs/BQWCHC_application_referral_form_oral_Health_Services.pdf