Mental Health Referral Form

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Transcription:

Mental Health Referral Form Mailing Address: Niagara Region Mental Health 3550 Schmon Parkway, Second Floor, Unit 2 P.O. Box 1042 Thorold, ON L2V 4T7 905-688-2854 Toll free: 1-888-505-6074 niagararegion.ca/health Please complete and return this form by fax to 905-684-9798. Patient Label Health Care Provider Stamp/Label Referral source information Fill out if details are not included in the stamp/label above Referral Contact Name: Referral Source Type: Phone and Ext.: Date of referral: Client information: Service Requested: Assertive Community Treatment Team (ACTT) Case Management Early Psychosis Intervention Geriatrics Youth Mental Health and Addiction Service First name: Date of birth (year/month/day): Last name: Age: Address: City: Phone (home): Marital Status: Common law Divorced Married Single Widowed Postal code: Phone (cell): Gender: Male Female Mental Health Referral Form Revised August 2018 1

Can a message be left at home? Highest Level of Education: Did not complete high school Completed high school Some post-secondary education Post-secondary degree, diploma or certificate (including trades) Identifies as Indigenous: Preferred language: English French Alternate Contact Name: Alternate Phone Number: Relationship to Client: Family Physician: Psychiatrist: Age at Onset of Mental Illness: Phone/Fax: Date of Last Visit: Age of First Psychiatric Hospitalization: Number of hospital visits in last 2 years for mental health: Number of hospital admissions in last 2 years for mental health: Reason for most recent hospital visit/admission: Reason for Referral: Psychiatric and Medical Diagnoses: Mental Health Referral Form Revised August 2018 2

Has the client consented to this referral? Is the client aware of this referral? Consent and Capacity: Is the client deemed capable of making treatment decisions? Does client have a substitute decision maker (SDM)? If yes, SDM Name: SDM Phone: If yes, has the SDM consented to this referral? Is the client on a community treatment order (CTO)? If yes, expiry: Diagnostic Category: Adjustment Disorders Anxiety Disorders Delirium, Dementia, Amnestic, and Cognitive Disorders Developmental Delay Disorders of Childhood/ Adolescence Dissociative Disorders Medication Eating Disorders Factitious Disorders Impulse Control Disorders t Elsewhere Classified Mental Disorders Due to General Medical Conditions Mood Disorders Personality Disorders Schizophrenia and Psychotic Disorders Sleep Disorders Somatoform Disorders Substance Related Disorders Unknown or Service Recipient Declined Name of medication Date started Dose Allergies (Medication & Environmental): Mental Health Referral Form Revised August 2018 3

Presenting Issues Activities of daily living Angry Anxious Coping issues Change in appetite Change in energy level Change in speech Confused Decreased motivation Delusional Depressed Educational Financial Gender issues Hallucinating History of trauma Housing Intrusive thoughts Legal Memory issues Mood swings Occupational/Employment/ Vocational Pain Paranoid/Suspicious Physical/Sexual abuse Poor insight Problems with relationships Racing thoughts Self-esteem Self-harm Sleep issues Stress Substance abuse/addictions Suicidal ideation Specific symptoms of serious mental illness Threat to others/attempted suicide Transition support Victim of violence Weight issues Risk assessment (check all that apply): Current Past (In last 5 years) Symptom(s) tes: Command hallucinations Danger to others Danger to self Fears consequences Homicidal thoughts Impulsive behaviour Medication compliance Poor social support Risk of falls Self-harm Suicide attempts Suicidal ideation Violent intention Willing to accept help Mental Health Referral Form Revised August 2018 4

Substance Use and Addictions: Past (in last 5 years) Current Past (In last 5 years) Substance(s) tes: (substance name, dose, frequency, and Alcohol mechanism - i.e. ingestion, inhalation, injection) Cigarettes Misuse of prescription drugs Recreational/Street drugs Behaviour(s) Gambling Pornography Sexual tes: agencies involved: Please include worker s name and contact information if known Canadian Mental Health Association Community Addiction Services of Niagara Counselling services Family and Children s Services Niagara Local Integrated Health Network (LHIN) (formerly Community Care Access Centre, or CCAC) Niagara Health Outpatient Program Shelters Niagara Seniors ne Worker Name: Worker Phone: Cage-Aid Questionnaire: When thinking about drug use include illegal drug use and the use of prescription drugs other than prescribed Question (please have client respond) Do you drink alcohol? Have you ever experimented with drugs? Have you ever felt that you ought to cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? Have you ever felt bad or guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? The following documents MUST be submitted with the referral if available: Most recent psychiatric consultation report(s) List of current medications (if not provided on page 3) Discharge summary Personal safety plan Mental Health Referral Form Revised August 2018 5

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