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Referral Form


Contact Information and Consent

Hello, thank you for taking the time to connect with our programming. Please fill out the information below to submit a referral on behalf of a Foothills community member.

Eligible locations will appear below, to match your selected category. If your referring residence is Rural Home Care, please select the "Community" option to provide your address.
Please select a referring residence type.
Which of the following best describes the person you’re referring:
Which of the following best describes the person you’re referring:
Any person referring to a Foothills Country Hospice program is asked to read the following statement to those they are submitting the form on behalf of. This is necessary for FCHS to obtain the rights to follow up for evaluations purposes. Thank you for your support!Consent Statement: The program you are being referred to is part of the work Foothills Country Hospice Society is undertaking to support our community. We would like to contact you in the future to complete a voluntary follow up survey. The survey will help us understand if we’ve supported a positive change in the community, if we need to make any changes, and to help us secure more funding in the future.
Please indicate the preferred mode of contact for follow up:
When was the loss experienced?
Which of the following best describes the type of loss the recipient has most recently experienced:

Age Group of Recipient

Program Referral

Please select the program you think is most beneficial for the person you are referring. Descriptions for each program are listed below.

Bereavement Boxes

Bereavement boxes support individuals following the loss of a loved one by providing role specific, physical grief resources, and coping strategies. It can be a tangible way for someone to have access to resources that they use in their own time.

Compassionate Conversations

Compassionate conversations support individuals following the loss of a loved one by offering connection and conversation with a trained bereavement volunteer. This is not a counselling service, but an opportunity to invite supportive and compassionate conversation into the grief journey.

Volunteers will offer up to one hour of conversation per month, and up to 12 months following the loss of a loved one.

Grief Group 

Grief Group is an opportunity for support among others who have similarly experienced a loss. It allows for conversation, compassion, and connection. We recommend that the person you’re referring be at least 3 months from the date of their loss before attending group.

Please note - Anyone referred to grief group will be contacted by a Registered Social Worker for a brief assessment to determine which group is the best fit for their needs.

Grief Counselling

Grief counselling with a Registered Social Worker is available to those who may benefit from more personalized supports in their grief experience. These short-term offerings are one hour long and can range from 1-3 sessions.

Once the referral is received, our social work team will call for a brief assessment prior to booking the first appointment.

Which Program(s) Would You Like to Submit?

Bereavement boxes support individuals following the loss of a loved one by providing role specific, physical grief resources and coping strategies. It can be a tangible way for someone to have access to resources that they use in their own time.
What is the best way for the recipient to receive their Bereavement Box?Please note that our deliveries are typically completed once per week by our volunteer team. If the box will be picked up, please allow for 2 business days for us to have it ready for you at the front desk.
Compassionate conversations support individuals following the loss of a loved one by offering connection and conversation with a trained bereavement volunteer. This is not a counselling service, but an opportunity to invite supportive and compassionate conversation into the grief journey. Volunteers will offer up to one hour of conversation per month, and up to 12 months following the loss of a loved one.
Was the death expected?
Grief Group is an opportunity for support among others who have similarly experienced a loss. It allows for conversation, compassion, and connection. We recommend that the person you’re referring be at least 3 months from the date of their loss being attending group. Please note - Anyone referred to grief group will be contacted by a Registered Social Worker for a brief assessment to determine which group is the best fit for their needs.
What is the preferred setting to attend grief group?
Grief counselling with a Registered Social Worker is available to those who may benefit from more personalized supports in their grief experience. These short-term offerings are one hour long and can range from 1-3 sessions. Once the referral is received, our social work team will call for a brief assessment prior to booking the first appointment.
What is the preferred setting to attend grief counselling?

Thank you for filling out the above information. Please fill out your preferred contact information below. We will only contact you if we have trouble connecting with the person you have referred.

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Referral Form

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