RRSCS Referral Intake/Application Form Icon

CLIENT INTAKE PROCESS


Completing our R&R Intake Application Form below is the first step in your Rehab and Retreat Senior Care Specialists journey. By providing the information requested in our intake form we are better equipped to create and plan a program that suits your loved ones needs.

This is not a one-size-fits-all approach.  We truly care about aligning our programming with our clients preferences from day one.

You can also download, print and complete the form here, then fax (780-761-2776) or scan and email the completed form back to info@rehabandretreat.com.

A response to your referral will be made within one business day of it being received. If you prefer to meet with Rehab and Retreat staff, prior to filling out referral, assistance with form can be provided.


Please call us at 780-758-2776 if you have any questions.

RRSCS Referral Intake/Application Form Collage

REHAB AND RETREAT SENIOR CARE SPECIALISTS LTD. (RRSCS) INTAKE/APPLICATION FORM


Client Information


Medical/Constitutional Consideration​

Max File Size: 20MB

Medical/Constitutional Consideration​


Client Support Information

Primary Caregiver Contact Info

Secondary Caregiver Contact Info

Other Health Care Professionals seen by this client(neurobiologist, physical therapist, etc)

Community Agency Involvement
Does the person you are referring receive or attend:




Having Trouble with the Application Form?

Don’t worry, we are here to help. Please submit any questions you may have in the box below.

Rehab and Retreat Referral Form Help

780-758-2776

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