Just Like Family Referral Form (VLRC) | Just Like Family Home Care

URL

This field is for validation purposes and should be left unchanged.

VLRC Lead Referral

VLRC Staff Email(Required)

Email address of VLRC member submitting the referral

Referral Contact Information

Please fill in all required fields. This is the contact information of the individual you are referring to us.

VLRC Client ID(Required)

This is the ID of the client within your client tracking system. If this is a referral for a lead who is not a client or is not currently in your system, you may enter 0 (zero) instead.

Client Email(Required)

Phone Number

Care Recipient's Postal Code(Required)

This is a critical field for matching the care recipient to the correct Just Like Family territory. We do not auto-validate this field. Ensure it follows the pattern : A1A 1A1

Preferred Contact Method

If the client indicated a preference, please select it here, otherwise you may leave it as “no preference”

Care Recipient's Province (optional)

This is the Province in which the person receiving care resides. Note that this might be different from the person requesting care for someone else.

Care Recipient's City (optional)

This is the nearest urban centre / city to the person who would be receiving care.

Care Recipient's Street Address (optional)

The full street address (including apartment / unit number, etc) of the person receiving care.

Care Needs

Other Service(s)

If you checked “Other” in the previous field, please type the other requested services in this field.

How urgently does the Client need care?

Select “Unsure” if this was not mentioned by the client.

Provide any additional information

For example, if there is a responsible party, please include their name, relationship to the client, and contact information if it differs from what was previously provided

Consent to Refer and Share Information

By submitting this referral form/request to be contacted by Just Like Family Home Care for an in-home consultation, the referred client provides consent to be referred to Just Like Family Home Care and consents to the release of relevant information to Just Like Family Home Care.

About Just Like Family Home Care (JLF)

VLRC Lead Referral

Referral Contact Information

Care Needs

Consent to Refer and Share Information