Referral Form for Aboriginal Health Coordinator

Circle of Indigenous Nations Society
Main Office: 1801 Connors Road Castlegar BC V1N 3N9
Boundary Office: 7525 12^th Street PO Box 1917 Grand Forks BC V0H 1H0
www.coinations.net

Aboriginal Health Coordinator Referral Form

Client information

Client name

Date

Ancestry – First Nations/Metis/Inuit/Other

If known (not required) FN/Metis status #

D.O.B

Health Care Number:

Phone #

Can we leave a message?

Yes

Do you have a Family Doctor or Nurse Practitioner?

Yes

If so, at which clinic?

Referral information

Person/Agency referring

Contact number for person making referral

Reason for referral

Other community agency involvement

Yes

Unknown

Agency/Programs

Informed consent signed

Yes

Other notes

West Kootenay Coordinator:

Phone: 250-608-4552 or 250-399-0731 ext. 103
Fax: 250-399-0731
Email: healthcoordinatorwk@coinations.net

Boundary Coordinator:

Phone: 250-444-9599
Fax: 250-352-0384
Email: healthcoordinatorgf@coinations.net

If you are human, leave this field blank.

Referral Form for Aboriginal Health Coordinator