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Let's Connect

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.

Who is completing this request?

Your Contact Information

First Name:

Last Name:

Phone Number:

Email:

Address:

Age (optonal):

Contact Information for the Person Needing Support

First Name:

Last Name:

Phone Number:

Email:

Address:

Age (optonal):

Whom should we reach out to?

How should we reach out?

Preferred Language?

What is your relationship to the person?

(check all that apply)

How can we help right now?

How can we help right now?

Are there any other services or supports currently in place?

Is there anything else we should know?

(Share details such as history, current challenges, diagnosis/prognosis, recent losses, etc)

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.