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Yukon Palliative Care Resource Team Consult Request

This one-page Yukon form starts a consultation with the Palliative Care Resource Team for a person living with a life-limiting illness. Health care professionals, family, friends or volunteers can complete it. The team offers education, consultation and health system navigation to providers, patients and families, but it does not coordinate primary care.

Who completes it

The referral source completes the whole form: client details, family doctor, diagnoses, location of care, allergies, Palliative Performance Scale if known, funding agencies and the reason for referral, then prints their name and agency. A medication list and relevant health history are attached.

Submitting and payment

How to submit it
Submit the completed form to the Palliative Care Resource Team by fax or email, using the contacts on the form or on Yukon's palliative care page.

Good to know

  • The form asks whether the client knows their disease status and prognosis, whether an advance directive has been completed, and whether they agree to the palliative care referral.
  • For clients in hospital, give the projected discharge date and location; the other care locations listed are home, a residential care setting or elsewhere.
  • Funding agencies on the form include private insurance, WCB and Veterans Affairs, and there are fields for First Nation and status number.
  • The current version is YG(6673HSS) Rev.09/2020. Beyond consults, the team gives providers best-practice information, assessment tools and clinical advice.

Get the official form

Download the current version from the source each time; forms change without notice.

Palliative Care Resource Team consult request form

Official pagePDF

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.

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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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who can request a Yukon Palliative Care Resource Team consult?

Health care professionals, family members, friends or volunteers can use the form to request support for someone with a life-limiting illness. The person completing it records the reason for referral and confirms whether the client knows about and agrees with the referral to the palliative care program.

What does the Palliative Care Resource Team do?

Through education, consultation and health system navigation, the team supports health care providers, people with life-limiting illnesses, families and caregivers. It offers best-practice information, assessment tools and clinical advice to providers, and links people to the right services, but it does not coordinate primary care.