The Multicultural Health Navigator program aims to educate newcomers to Ottawa about the Canadian Healthcare system and assist with system navigation. Services include: • Enhance health literacy, health promotion and system navigation • Bridge between clients and service providers • Routine home visits and occasional appointment accompaniment Please check this box, if you are requesting health navigation services for yourself Please check this box, if you are requesting health navigation services for someone else If you are requesting services for someone else, have you informed the person that they will be referred to our services? Yes No Referral Requested by:* Name of Organization:* Phone*Ext. Email* ConsentIf referral is accepted, is it okay to save the information below in our client record system?* Yes No DetailsName:* First Last Date of Birth (YYYY/MM/DD):* Address:* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone (home):Phone (mobile):*Best way to leave a message:* Message can be left on the home phone Message can be left on the mobile phone Preferred Language of Service:* We can provide home visits as part of our services. Are home visits preferred?* Yes No Please check off the service(s) being requested:* Health Navigation Services Connection to Settlement Services Connection to Social Services Health System Education Other If you picked "Other", please provide details below: Does your client have an ongoing Primary Healthcare Provider?* Yes No Does your client have Chronic health Issues?* Yes No Additional Information (you may attach additional documents)Please provide any relevant information*Please attach any relevant documents in one of the following formats – MS Word (.doc or .docx), PDF (.pdf), Image (.jpg, .png, .gif)FileAccepted file types: doc, docx, jpg, gif, png, pdf, Max. file size: 32 MB.Internal Use OnlyNavigator / Language: Priority (1,2,3): Date of Receipt: Δ
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