CMHA - Eastern Branch: Referral Form

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Referral Form

Referral Form

General Information

Name:

D.O.B:

Gender:

Street Address:

City:

Province/Territory:

Postal Code:

Telephone:

Next of Kin (For Emergencies)

Name:

Relationship:

Street Address:

City:

Province/Territory:

Postal Code:

Business Tel:

Residential Tel:

1. Reasons for Referral

Please check those below that would apply to your current needs and/or difficulties:

Self Esteem	Depression	Physical/Sexual Abuse
Life skills	Substance Abuse	Social Skills
Housing	Legal Problems	Employment
Social Isolation	Support	Anxiety
Family	Stress	Financial
Learning Community Resources	Other - Please list

History of Violence/Aggression?
If yes, give details

Yes No

2. Psychiatric History

Diagnosis:

Psychiatrist:

Approximate Onset of Illness:

Current Medications:

Name of Medication 1: Dosage: Frequency:

Name of Medication 2: Dosage: Frequency:

Name of Medication 3: Dosage: Frequency:

Name of Medication 4: Dosage: Frequency:

History of Psychiatric Hospitalizations

Name of Facility 1: Date: Length of Stay:

Reason:

Name of Facility 2: Date: Length of Stay:

Reason:

Name of Facility 3: Date: Length of Stay:

Reason:

3. What additional support/services are currently being accessed in the community:

Agency 1:

Type of Service:

Contact Person and Phone Number:

Agency 2:

Type of Service:

Contact Person and Phone Number:

Agency 3:

Type of Service:

Contact Person and Phone Number:

4. Physical Health

Name of Family Physician:

List any current medical health problems and medications prescribed:

5. Referral Source Information

Name of Doctor/Agency :

Caseworker:

Address:

Phone Number:

Date:

Note: If self referral please indicate how you were made aware of our services: