Thompson Centre Intensive Treatment Program Physician Referral Form

Transcription

1 FREDERICK W. THOMPSON ANXIETY DISORDERS CENTRE Website: Phone: ext 100 Fax: Thompson Centre Intensive Treatment Program Physician Referral Form Dear Referring Provider, Welcome and thank you for considering the Frederick W. Thompson Anxiety Disorders Centre for treatment for your patient s obsessive compulsive disorder (OCD). Our Centre specializes in the treatment of OCD and related "spectrum" disorders, including hoarding, hair pulling (trichotillomania), skin picking and body dysmorphic disorders. The following must be submitted as part of the referral (please submit all items at once): Physician Referral Form to be completed by the referring physician Thompson Centre Intensive Residential/Day Treatment Client Information Package to be completed by the client Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF) to be completed by the client Florida Obsessive Compulsive Inventory (FOCI) to be completed by the client Eligibility Criteria Age is between years Principal diagnosis is OCD (if there are comorbidities, OCD must be disorder that causes the greatest amount of daily impairment) Symptoms must be judged as severe (FOCI score 15+) Patient s functioning is severely impaired OCD symptoms must be treatment resistant. Specifically, the illness has not responded to: 2 or more SSRIs AND 1 or more trial of clomipramine or SNRI (Effexor, Pristiq) AND 1 or more augmentation agent (atypical antipsychotics, memantine, or topiramate) * AND 1 trial of evidence-based CBT* Willingness and motivation to challenge OCD symptoms Patient must have GP and ideally a therapist in their community willing to provide ongoing medication management and therapy We are generally unable to provide care if the patient exhibits any of the following (patients with the following issues may not be eligible for an episode of care through our severe service): Current psychotic symptoms Current active trauma-related symptoms Current active suicidality Current active anorexia nervosa Active substance dependence (within last 6 months) *If your patient does not fit our criteria above but you feel they should be seen by the Thompson Centre, please outline the reason below: Thank You, The Frederick W. Thompson Anxiety Disorders Team Version October 2017 Page 1 of 7

2 Thompson Centre Physician Referral Form Date: Intensive Residential and Day Treatment Program Requested treatment Residential Day Program* *Day Program: This is an option for patients whose functioning will allow them to reliably attend core programming between 9 a.m. to 5 p.m. while residing at home. REFERRING PHYSICIAN INFORMATION Referring Physician Name: MD Billing #: Address: Phone Number: Fax Number: Does this patient currently have a psychiatrist? Name: Phone Number: Postal Code: PATIENT INFORMATION Last Name: First Name: Gender: Address: Male Female Transgendered Non-binary Other Postal Code: Date of Birth (dd/mm/yyyy): OHIP #: Version Code: Phone Number: Can a message be left? Yes / No With another person? Yes / No Name: Relation: Phone Number: Please provide a brief history of the patient s OCD including current symptoms: Version October 2017 Page 2 of 7

3 What is the patient s current level of functioning? Can they work/attend school? How impairing is the OCD? Can they perform their activities of daily living (ADL s)? Please list any co-morbid psychiatric conditions that may interfere with treatment. Please note current state of these conditions: Is there any current/past substance abuse history, including any treatment for substance abuse? Does the patient have any history of acting violently or demonstrating aggressive behavior? Any legal issues? Does this patient have a history of impulsive or self-injurious urges? If so, what are these behaviors? What coping skills has he/she learned to try to manage the urges? Has this patient ever attempted suicide in the past? Please provide details (i.e., When did this occur, method of attempt?) Version October 2017 Page 3 of 7

4 Is there any current suicidal ideation? If so, please describe. Please tell us about the patient s current support system and living situation. Is their living situation stable and can they return there after treatment? How involved is the patient s family in their care? Does the family accommodate the patient s OCD (i.e., provide reassurance with respect to their obsessions and or compulsions; do they participate in rituals for the patient?) Medical and Treatment History Please provide information about the patient s medication history (if applicable), including any medical issues and what type of care is required to manage them. Current Psychiatric Medication Please list any medication that the patient is currently taking for his/her mental health (e.g. anxiety, depression, etc.). Include dose, duration, response and patient s tolerance of the medication. Medication Reason Dose Duration Example: Cipralex (much improved, minimally improved, no change, minimally worse, much worse) OCD 20mg 1 year Minimally improved Tolerability (side effects: none, mild, moderate, severe) Mild side effects Version October 2017 Page 4 of 7

5 Past Psychiatric Medication Please list any medication that the patient has taken in the past for his/her mental health. Medication Reason Dose Duration (much improved, minimally improved, no change, minimally worse, much worse) Tolerability (side effects: none, mild, moderate, severe) Current and Past Psychotherapy Please list any current or past psychotherapy that the patient has received. Type of therapy Group/ Individual Reason Frequency Duration Dates (start and end) (much improved, minimally improved, no change, minimally worse, much worse) How much experience does the patient have doing CBT/exposure therapy, either with you or another clinician? If so, please describe: How motivated do you feel your patient is to engage in an intensive and demanding treatment program at this time? Please describe. Version October 2017 Page 5 of 7

6 What do you identify as barriers to this patient s ability to benefit from and participate in treatment (i.e., interpersonal style; level of insight into symptoms, ability to grasp skills and concepts; significant cognitive challenges; secondary gains)? Are you and the patient in agreement that treatment in this program is an appropriate course of action at this time? Do you believe your patient is better suited to residential treatment or our day treatment program? Current and Past Medical History Please check all that you have been diagnosed with in the past: Heart Failure High Cholesterol Liver Disease Diabetes Thyroid Problems Kidney Disease Heart Condition Asthma Stroke Seizures/Epilepsy Intestinal Problems Reflux Disease Glaucoma Arthritis High Blood Pressure/hypertension Heart Attack/By-pass Surgery Cancer: (Type & Location) Other: Details (if said yes): List any drug allergies: Version October 2017 Page 6 of 7

7 Current Non-Psychiatric Medication Please list any medication that the patient is taking for medical, non-psychiatric, conditions i.e. diabetes. Medication Reason Dose Duration (much improved, minimally improved, no change, minimally worse, much worse) Previous Medical Hospitalizations Not Applicable Example: Head injury, concussion, broken bones, surgical procedures Date Hospital Reason Previous Psychiatric Hospitalizations Date Hospital Reason Not Applicable Version October 2017 Page 7 of 7