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2SLGBTQIA+ Nurse Liaison Referral

Please complete the form below to submit a referral to the 2SLGBTQIA+ Liaison Nurse

At the presant this role is primarily serving patients while admitted to the Victoria General Hospital. Referrals from other hospitals or settings are helpful to build future capacity, however, for the time being the focus will be on Victoria General Hospital.

As there is only one 2SLGBTQIA+ Liaison Nurse we will prioritize the activiated sites. However will provide support elsewhere as capacity allows. Referrals will also help us capture data on times and areas of need and support expansion of funding.

If you would like more information you can visit our website: 2SLGBTQIA+ Liaison Nurses | Island Health

If you have questions, comments, or concerns please email SI.2SLGBTQIANurseLiaison@Islandhealth.ca

Please select who is submitting this referral.

* must provide value

Island Health Physician

Island Health Nurse

Island Health Allied Health (ILN, SW, PT/OT, etc.)

Community Health Provider

Patient Self Referral

Patient Family Referral

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Referrer Name

* must provide value

Referrer Professional Designation

* must provide value

Referrer Relationship to Patient

* must provide value

Patient First Name

* must provide value

Hospital or Site

* must provide value

If other, please specify site or hospital

* must provide value

Patient Pronouns

* must provide value

If applicable, select identified needs

* must provide value

Health Advocacy

Personal or familial support

Personal or familial education

Community 2SLGBTQIA+ Health Resources

Sexual Health Resources

Gender affirming care community resources

Hormone Readiness Assessment

Surgical Readiness Assessment

Legal name or gender change support

2SLGBTQIA+ Social Resources

Other

No specific need

If other or you feel the need to provide additional information please add any relevant context.

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What is your phone number?

* must provide value

Phone Number or Extension

* must provide value

Island Health Email?

* must provide value

Optional: What is your email address?

Referrer Email Address

* must provide value

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