COPA PROGRAM REFERRAL FORM Person must be: Years -Living with Addictions -Living within the Toronto Central LHIN boundaries

Transcription

1 COPA PROGRAM REFERRAL FORM Person must be: Years -Living with Addictions -Living within the Toronto Central LHIN boundaries CLIENT INFORMATION First Name: Last Name: Referral Date: Form completed by: Client Caretaker/family Service Provider Health Card #: Version Code: Age: DOB: / / mm / dd / yyyy Ethnicity/culture: Phone #: City: Province: Do you speak English? Preferred Language: Do you need an interpreter: Yes No Street Address: Unit #: Postal Code: Male Female Trans: Other: REFERRAL SOURCE INFORMATION Name: Title: Organization: Phone #: Fax #: Relationship to client: Reason for the referral: Is the client aware of the referral and have you obtained explicit consent (written or verbal) from the client or their Substitute Decision Maker for this referral? Yes No Do you intend to remain involved with the client if he/she secures this service Yes No Substitute Decision Maker name: Contact # Page 1 of 5

2 CURRENT CLIENT SITUATION HOUSING: currently housed homeless What type of housing do you presently live in? Market Rent Subsidized Room/boarding home Shelter Long Term Care Correctional Facility Other: Housing Support type: Independent Assisted/Supported Supervised Living Arrangement: Living alone Living with non-relative Living with Relative(s) Living with spouse/partner Living with children INCOME/ EMPLOYMENT: What is your primary source of income? OW ODSP CPP OAS Private Pension Other: Are you currently employed? Yes No Please describe EDUCATION: What is your highest level of education? Are you currently in school? Yes No LEGAL: Are you currently involved in the criminal justice system? Yes No Unknown If yes, please describe: PHYSICAL HEALTH Do you have any health conditions/chronic illnesses and/or physical disabilities? Please describe all: Page 2 of 5

3 PHYSICAL HEALTH (cont.) Do you have any health conditions/chronic illnesses and/or physical disabilities? Please describe all: Are you currently on any medications? Yes No Unknown If yes, Prescribed meds Over the counter meds Mobility issues: Yes No Vision issues: Yes No Hearing issues: Yes No MENTAL HEALTH Do you have concerns about your mental health? Yes No Unknown Unsure Have you been diagnosed with mental illness? Yes No Unknown Are you currently on any psychiatric meds? Yes No Unknown Do you have any immediate safety concerns for your mental health/wellbeing (including selfharm/suicidality)? Page 3 of 5

4 MENTAL HEALTH (cont.) Do you have any memory problems/cognitive impairments? None Suspected Diagnosed SUBSTANCE USE/GAMBLING Do you have gambling concerns? Yes No Unknown Unsure Do you have substance use concerns? Yes No Unknown Unsure Have you been diagnosed with substance use disorder? Yes No Unknown Please list all substances: Your thoughts/concerns about your use: Page 4 of 5

5 HOSPITALIZATIONS: Have you visited the Emergency Department or have been hospitalized within the last two years due to mental health/physical health/ substance use? Yes No Unknown # of Emergency Department visits in the past 2 years: # of Emergency Department visits in the past 6 months: Date of last hospitalization Reason: CURRENT SUPPORTS Please list all current treatment providers (GP, psychiatrist, etc.) and community supports (family, support workers, etc.) who are working with you right now: Name Role/Relationship Organization Phone # Page 5 of 5