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Referral Form

Getting started with one of our programs is easy! Just fill out this form, and once it’s submitted, we’ll be in touch.

If you have questions, or just want to talk to someone, feel free to call us at 905-984-8766 or send us an email at info@hospiceniagara.ca.

At Hospice Niagara, we’re dedicated to making sure everyone feels welcome, safe, and respected while accessing care and support.
You can learn more about our commitment to accessibility and inclusivity by checking out our policies.

First Name:

Last Name:

Home Phone:

Cell Phone:

Email:

City:

Please check all programs that are of interest to you:

Is there any additional information that may be helpful for us to know about the reason(s) you would like support?

If you have an urgent medical concern or are experiencing a medical emergency, please contact your community nurse or call 911. If you are experiencing an urgent mental health concern or crisis, please contact COAST at 1-866-550-5205.

Please contact us at 905-984-8766 to ensure your accessibility needs are accommodated through this process. Information received relating to accommodation measures will be addressed confidentially.