Community Care for Social Support: COVID-19 Referral Form

Referral source information
Relationship to client
Client Information
How is this person or household affected by COVID-19? Include where and when they were tested, if they have symptoms, and, if they’ve had close contact with a person confirmed to have COVID-19, describe their last interaction with that person.
Please include # of household members known to have COVID-19 and # who are close contacts.
For any language other than English, please share the person’s nationality to ensure accurate translation and interpretation services.
Include any other important information, such as whether the person is at high risk of COVID due to their living situation, job, or health.