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You are here: Home / Our Services / Multicultural Health Navigation / Multicultural Health Navigator Program – Referral Form

Multicultural Health Navigator Program – Referral Form

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

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:(Required)

Name of Organization:(Required)

Phone(Required)

Email(Required)

Consent

If referral is accepted, is it okay to save the information below in our client record system?(Required)

Yes

No

Details

Name:(Required)

First Last

Date of Birth (YYYY/MM/DD):(Required)

Address:(Required)

Street Address Address Line 2 City Province Postal Code

Phone (home):

Phone (mobile):(Required)

Best way to leave a message:(Required)

Message can be left on the home phone

Message can be left on the mobile phone

Preferred Language of Service:(Required)

We can provide home visits as part of our services. Are home visits preferred?(Required)

Yes

No

Please check off the service(s) being requested:(Required)

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?(Required)

Yes

No

Does your client have Chronic health Issues?(Required)

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)

File

Accepted file types: doc, docx, jpg, gif, png, pdf, Max. file size: 32 MB.

Internal Use Only

Navigator / Language:

Priority (1,2,3):

Date of Receipt:

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