SENIORS MENTAL HEALTH BEHAVIOURAL INPATIENT REFERRAL FORM ADMISSION DEMOGRAPHIC PATIENT S PERSONAL INFORMATION: Last Name: First Name: Male Female Address: Apt. City: Prov. Postal Code: Home Telephone: Present Location: Date Admitted (yyyy/mm/dd) Date of Birth (yyyy/mm/dd): Age: Marital Status: Single Married/Partner Separated Widowed Divorced Preferred Language: Other Languages: Religion: DIAGNOSIS: Family Physician: Phone: Fax: Consulting Physician: Phone: Fax: HEALTH INSURANCE INFORMATION: Is patient covered under Ontario Health Insurance Plan? Yes No Health Card Number If NO, indicate other health insurance plan: CONTACT INFORMATION: Next of Kin: Power of Attorney: Relationship: Personal Care Financial Address: City: Province: Postal Code: Telephone (Home): Telephone (Work): Ext: Primary Contact: Power of Attorney: Relationship: Personal Care Financial Address: City: Province: Postal Code: Telephone (Home): Telephone (Work): Ext. Version Code: CLINICAL ALERTS: Allergies: No Yes Specify: Diabetic: No Yes CPR Status: Full Code No Code Not discussed: Current Infections: MRSA: No Yes VRE: No Yes Other: Date of TB Test: Step 1: Step 2: Flu Shot: Yes No Date of Last Flu Shot: REFERRAL SOURCE: Referral Site Date: Primary Contact: Phone: Ext: Pager: Primary Contact E-mail: Alternate Contact: Phone: Ext: Pager: Please fax all referrals to: Seniors Mental Health Behavioural Program St. Joseph s Healthcare, Hamilton Mental Health & Addiction Program Fax: 905-381-5620 Intake Phone: 905-522-1155, Ext. 36649 Referrals may be reviewed with CCAC and St. Peter s Behavioural Health to Page identify 1 of the 5 best level of care to complete a behavioural assessment
MEDICAL HISTORY (attach info as needed): PSYCHIATRIC HISTORY (include hospitalizations): Geriatric/Geriatric Psychiatry Team Involved: Yes No Name: BSO Team involved: Yes No PRC (Psychogeriatric Resource Consultant): Yes No Name: High Intensity Funding Utilized: Yes No Name: Contact Person: Date of last consult: Phone: PRESENT MEDICATIONS (please attach medication profile MARS) BEHAVIOURAL ISSUES: Physical: Verbal: Sexual: Behavioural Triggers: CMAI (Cohen Mansfield Agitation Inventory) to be attached RESTRAINT USE: Past or Current Restraint Use: Yes No Type of restraint(s) used: Reason for restraint use: Response to restraint use: Page 2 of 5
COGNITIVE ASSESSMENT: Orientation: Person: Place: Time: Memory: Language, Spatial Orientation & Coordination THINKING: Logical Disorganized Coherent Incoherent Other: (describe) HALLUCINATIONS: Yes No Auditory Visual Olfactory Tactile Taste Describe, including the effect on client: DELUSIONS: Yes No Describe the common theme(s), including the effect on client: MMSE or SMMSE Score: Date: Clock Drawing Assessment: COMMUNICATION ASSESSMENT: Hearing Aid(s): Yes No Eye Wear: Yes No Language spoken: Interpreter needed: Yes No Communication Problems: FUNCTIONAL ASSESSMENT (complete table below): I=Independent ; S=Supervision; Min A=Min Assist-1 Person; Mod A=Mod Assist-2 Person; Max A=Mech. Lift; D=Dependent Bathing Dressing Feeding Swallowing Communication/Aphasia Transfers Walking Wheelchair Mobility Baldder Continence Bowel Continence Ostomy: Yes No Pacemaker: Yes No CURRENT STATUS Mobility Aids: Cane Walker Wheelchair: Owned by Patient Yes No Weight Bearing Status: Full Partial Non-Weight Bearing Movement Restrictions/Precautions List: PROVIDE DETAILS Manual or Power Page 3 of 5
NUTRITIONAL ASSESSMENT: Weight (kgs): Height: Recent weight gain/loss: Diet: Diet Texture: FALLS ASSESSMENT: Falls risk identified due to (check all that apply): Ambulation Behaviour Cognitive/perceptual deficits Climbing out of wheelchair Climbing out of bed Unsteady Gait Date of last fall & description: SKIN ASSESSMENT: Clear & Intact (present) Yes No Past history of skin breakdown: Yes No Location and description of past or present skin breakdown: REASON FOR ADMISSION TO CURRENT FACILITY: GOALS FOR ADMISSION TO SENIORS BEHAVIORAL MENTAL HEALTH PROGRAM: Page 4 of 5
SENIORS MENTAL HEALTH BEHAVIOURAL PROGRAM MISSION We provide compassionate, quality care to patients with complex behavioural needs related to dementia, and provide support to their caregivers. VISION Honoring life through caring THE FOLLOWING MUST BE ATTACHED WITH REFERRAL FORM: Medication profile (MARS) Consultation reports Cohen Mansfield Agitation Inventory (CMAI) Mini Mental Status Examination Clock Drawing Assessment (if available) Recent Laboratory Results & CT/MRI, if available Chart Notes (Progress Notes for last week) Interdisciplinary Assessments, i.e. TR, OT, PT, SW, SLP Page 5 of 5