Social Prescribing Program for Seniors

Referral Form

The Social Prescribing Program supports seniors to access non-clinical, non-medical, community-based services to prevent or delay frailty by fostering resilience and social support using a comprehensive, strength-based approach. Parkgate Services Society is one of 19 organizations in BC funded by the Government of BC and managed by the United Way to provide a social prescribing program for seniors. Chronic conditions can be exacerbated by the loneliness experienced by patients. A social prescribing program aims to reduce primary care visits and health care spending by addressing social determinants of health and enhancing the social connections of isolated seniors at risk of frailty. Through a person-centered process with a community connector, seniors are supported to overcome barriers and access meaningful activities, services, and programs for as long as possible in their community.

Referrer Information

Name: (required)

Profession/Title: (required)

Phone: (required)

Email: (required)

Referral Date: (required)

Patient/Client Information

Name: (required)

Address: (required)

PHN: (required)

DOB: (required)

Phone: (required)

Email:

Referral Criteria (include brief description / specific concern):
Senior (55+) living in North Vancouver experiencing:

Social Isolation:

Physical Inactivity:

Frailty or danger of frailty:

Diagnosed for Cognitive Decline:

Are there any concerns, restrictions or limitations to be aware of? Any additional notes:

Here are some examples of social prescribing:

Physical Activity Programs
Nutrition/Food Programs
Social Programs & Services
Access to Information and Support

Social Prescribing Program for Seniors

Referral Form

Here are some examples of social prescribing:

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