Near North Palliative Care Network

A Special Thanks to:

Assante

Caisse Populaire North Bay limitée

North Bay & Area Community Foundation

IBM Canada Ltd

North Bay Cruisers

Dr. Ken Runciman

United Way Toronto

Knights of Columbus 1007

Rebuilt Resources Skills Development Inc.

Northern Business Solutions

Mac's Office Supplies

Moose FM North Bay 106.5

Ohana Wellness Centre

Aha Communications

Boyd Print and Design

Chevaliers De Colomb #12101

Chevaliers De Colomb #8163

Hillside Funeral Homes

KFM North Bay

IODE Dr. Herbert A. Bruce Chapter

Widdifield Lions Club

Bonfield and District Lions Club

Northern Business Solutions

Widdifield Lions Club

Northern Business Solutions

A&A Entertainment

Aggies Flowers

Bell Canada Employee Giving Program

BEAM Blue Sky Net

Sofa Communications

Saint Peter's Church

Chip Kean and 22 Wing Band

The McCubbin family

Richard Smith, NBRHC Pastoral Care Team, and Palliative Care Committee

Miranda Weingartner

Gen McRae

Cheryl Gates, Respiratory Technician

Darren Renaud

Carol Owens

Marilyn Weingartner

Heather McGuinty, Case Coordinator for the CCAC

Bev Charron

Oriana Webster, NBRHC Volunteer Coordinator

Steve Lamb, Aids Committee

The Rheaume Rochefort Family

Jeff Johnson at Cambrian Technical Services

Client Application Form

If you prefer a printed copy of our form, please click here.

Part 1. General Information

Client’s First Name

Client’s Last Name

Phone Number

Date of Birth:

Street Address:


City:


Province:


Postal Code:

Email Address:

Are you the client?
yesno

If NO, specify your name, phone number and relationship to the client you represent:

Name:


Phone number:


Relationship to the client:

Is the client* currently being seen by a health care professional?
yesno
(* The client = you or the client you represent)

If YES, specify the name and area of specialization of the health care professional:

What are you looking for?
Telephone SupportPalliative Care ServicesRespite ServicesBereavement Individual SessionBereavement Group SessionInformationMedical Loan CupboardLending LibraryEducation and Training
Other (specify)

Best time to contact you:
MorningAfternoonEvening

Health care services being provided to you/to the client:
Medical CareSocial Worker SupportPalliative Care ServicesRespite ServicesHome Support ServicesBereavement Individual SessionsGrief Information EveningsGrief Self-Help Support GroupSupport GroupStill on waiting list
Other (specify)

How did you hear about our service? BrochureFamilyFriendWebsite
Other (specify)

PART 2. If you are looking specifically for Bereavement and Grief Services please fill the information below

Name of the Deceased

Date of Death:

Your relationship to the Deceased:
WifeHusbandDaughterSonSisterBrotherMotherFatherFriend
Other (specify):

Nature of Death:
UnexpectedExpectedIllness/Long TermSuicideCrimeAccident (vehicle, work related, fire, etc)Child DeathStillbirth

If Illness/Long Term, Suicide, Crime, Accident or Child death, please specify:

Connect with us

Main Office:
St. Joseph Motherhouse
2025 Main Street West
North Bay, ON  P1B 2X6
Phone: (705) 497-9239
1-800-287-9441
Fax: (705) 497-1039
Hours:
08:30-16:30 Monday-Friday
(closed for lunch between 12:00-13:00)

Mattawa Office:
(705) 744-3771 Fax: (705) 744-2787
West Nipissing Office:
(705) 753-5771  |  Fax: (705) 753-6130