Referral from the patient's health-care team for hospice admission in a Yukon continuing care facility.
- Completed by
- Member of the patient's health-care team
- Issued by
- Yukon Health and Social Services - Continuing Care
- Format
- Language
- English
Yukon Continuing Care Facility or Day Program Referral
This four-page Yukon form, formerly called the CCTRF, refers a person for permanent long-term care placement, respite, reablement, hospice, hospice respite or the community day program. It gathers medical history, code status, function, cognition, nutrition, equipment and contacts. Continuing Care screens referrals for eligibility and assesses applicants before admission to one of Yukon's four long-term care homes.
Who completes it
Referrals are accepted from any source, including the applicant, family or caregiver, or a health care provider, and the form records who compiled it and when. It captures diagnoses, code status, advance directive, psychiatric history, drug allergies, vaccines and a TB clearance date, and day program applicants complete an extra section.
Submitting and payment
- How to submit it
- Fax the completed form to the Continuing Care admissions office, using the number printed on the form.
Good to know
- A TB clearance date is mandatory, and the form also asks for flu shot and COVID-19 vaccine dates, code status and whether an advance directive is in place.
- Eligibility requires a valid Yukon health care card, an assessed need for long-term care, legal status in Canada, and Yukon residence for 12 consecutive months or 10 consecutive years in a lifetime.
- Hospice admission also needs the separate Hospice referral form (YG 6898), completed by the health care team and sent with this referral.
- The equipment section flags IV medications, tracheostomy, chemotherapy, PICC or central lines, ventilator, CPAP or BiPAP settings, pleural catheters, defibrillator deactivation and oxygen needs.
Get the official form
Download the current version from the source each time; forms change without notice.
Continuing care facility or community day program referral
Fill it with Vero
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Frequently asked questions
Who can submit a Yukon continuing care referral?
Yukon accepts referrals for long-term care admission from any source, including the applicant, their family or caregiver, or their health care provider. Referrals are screened for eligibility, and applicants are assessed before they are admitted to a long-term care home.
Which services does the YG 5794 referral cover?
One form covers permanent placement, respite, reablement, hospice, hospice respite and the community day program. Day program applicants also list requested attendance days, transportation, reasons for referral such as social, nutritional, cognitive or emotional needs, and whether a bath is requested.