SSIPP Client Referral Form
Thank you for your interest in the Student-Senior Isolation Prevention Partnership (SSIPP). We work to partner health professional students with older adults 65+ to provide social connection and promote health literacy.

Please fill out provider and client information in the sections that follow. Once the referral has been received, we will call each client to explain the program, confirm their interest in participation and answer any questions they might have before assigning them to a student volunteer.

Please do not include any health identifying information on this form.

If you have any questions about this form or the program please email ssipp.manitoba@gmail.com.
Name of referral source *
Name of associated Clinic/Agency *
Referral source phone number *
Referral source email address
Are you comfortable being contacted in the event that a volunteer raises a concern regarding the wellbeing of this client? *
The client has been informed and agreed to this referral. *
Client full name *
Client phone number *
Language (if not english)
Would you like to receive our monthly referral source email newsletter?
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