Dear Referring Provider: Thank you for referring your patient to the Frederick W. Thompson Anxiety Disorders Centre at Sunnybrook Health Sciences Centre. The attached form will assist us in determining eligibility and appropriateness of your patient for the Intensive Residential and Day Hospital Program for adults with severe obsessive compulsive disorder (OCD). The Thompson Centre s Intensive OCD Treatment Program model integrates psychological and psychopharmacology interventions to provide a comprehensive approach to care for people with severe and impairing OCD. The model includes medication management, individual CBT and group treatment. The key modality is Exposure and Response (or Ritual) Prevention (ERP), the gold standard for treatment of OCD, which will occupy a significant portion of treatment time each day. Additionally, participants in the program will benefit from occupational therapy, comprehensive discharge planning, family therapy, and recreational activities. Services are delivered by a highly skilled multi-disciplinary team at a satellite site with excellent facilities including a well-equipped gym, laundry, kitchen and living areas. The average length of stay in the program is 6-8 weeks, but can be up to 12 weeks or more and is determined by the patient s progress, engagement in the program, and adherence to program policies/guidelines. Not all patients are suited for this type of treatment program. To determine if our treatment program will meet a patient s needs, we conduct a thorough assessment including patient and family self-reports, and Physician s information. Patients coming to the program must have a primary diagnosis of OCD, and these symptoms should be what most interfere with their functioning. Patients who tend to do well in our program are those who show a willingness and ability to engage in treatment, but whose symptoms are significantly severe such that outpatient treatment is not sufficient. Conversely, patients who tend not to do well in our program are often unable or unwilling to participate in an active, intensive treatment setting. We recommend that patients who have comorbidities which will interfere with their ability to do CBT should have those conditions treated first. For this reason, patients with active or recent psychosis, active substance use disorders, self-injurious behaviors, or active eating disorders may not be appropriate. People coming to the program must be able to participate in both group and individual therapy daily (with assistance), be able to take care of their activities of daily living (ADLs) at least with coaching, and cannot be disruptive to the patient milieu such that they are interfering with others care. We also recommend that patients have a stable living situation to which they can return after discharge to support the gains that they have made within the treatment program. Please note that this is not an inpatient setting and patients must be able to manage in the residential setting with limited supervision at night. Please complete the physician referral form, to be submitted with the other referral package documents. If you prefer to write a separate report, please include the answers to the questions outlined. Please do not send us handwritten office notes, as these do not provide the history and level of detail required to make an adequate assessment. We look to our patient s outpatient provider for information that will assist us in their care. We also ask that you, or an identified provider, confirm that you will follow the patient closely upon their return from the treatment program to support their transition back, and to ensure their gains are consolidated. Once all materials are received (including those from the patient) and reviewed, our intake coordinator will contact the patient for a telephone screen. It may take up to 4 weeks for an admission decision to be finalized. We look forward to a collaborative relationship with you including contact throughout the patients stay and at discharge to ensure optimal transfer of care. If you have any further comments or concerns regarding the appropriateness of your patient for our intensive group therapy milieu, please do not hesitate to contact us. 1
The following must be submitted as part of a completed application: Physician Referral Form to be completed by the referring physician Client Information Package to be completed by the applicant Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF) to be completed by the applicant The Florida Obsessive Compulsive Inventory (FOCI) to be completed by the applicant Information can be faxed to 416-480-5866 Sincerely, Frederick W. Thompson Anxiety Disorders Centre 2
Frederick W. Thompson Physician Referral Form Intensive Residential and Day Treatment Program Referring Provider: Patient Name: Please describe the patient s history of OCD including current symptoms: What is the patient s current level of functioning? Can they work/attend school? Can they perform their ADL s? 3
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? 4
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?) Is there any current suicidal ideation? 5
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: 6
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 (weeks/months/yrs) Example: Cipralex OCD 20mg 1 year Response (much improved, minimally improved, no change, minimally worse, much worse) Minimally improved Tolerance (side effects: none, mild, moderate, severe) Mild side effects Past Psychiatric Medication Please list any medication that the patient has taken in the past for his/her mental health. Medication Reason Dose Duration (weeks/months/yrs) Response (much improved, minimally improved, no change, minimally worse, much worse) Tolerance (side effects: none, mild, moderate, severe) 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 (weeks/months/yrs) Response (much improved, minimally improved, no change, minimally worse, much worse) Tolerance (side effects: none, mild, moderate, severe) 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. 8
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? 9