SSIPP Older Adult Referral Form
Please fill out this short survey to refer an older adult to SSIPP chapters across Canada.
Disclaimer: SSIPP is a friendly phone call student volunteer-based service and does not provide medical care of any sort.
1.
Which SSIPP chapter are you referring from? (If you are referring from a health care provider's office, enter your city.)
University of Calgary
University of Saskatchewan
University of Manitoba
University of Toronto
University of Western Ontario
University of Ottawa
Trent University
2.
First and Last name of Older Adult
3.
Phone Number of Older Adult
4.
Referring Health Care Provider Name
5.
Referring Health Care Provider Phone Number
6.
What is the relation of the referring provider with the older adult (physician, nurse, etc.)
7.
Optional: Emergency Contact Name and Number (Name, Number)
8.
Language Spoken (If Other than English)
9.
Optional: Additional Comments
Thank you for your referral! We will do our best to match the older adult with a SSIPP volunteer as soon as possible. Please note that the older adult may be matched with a volunteer from another chapter.