Rev. 12/2018 (v1)
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Chart Copy − Do Not Destroy
Page 1 of 5
Adult Outpatient Referral Form
Mental Health and Addictions
Pages 1 and 2 must be completed in full for all referrals (incomplete forms will not be processed)
Additional Required Information Form must be completed
for all referrals Medication Clinic (Pg. 3), ECT (Pg. 4), rTMS (Pg. 5)
Please fax all referrals to: 905−704−4420. For any enquiries, please call Intake at 905−378−4647 Ext. 49613
SECTION A: Client Information Is client aware of referral? Yes No
Client Name: ______________________________ HC with Version Code: ____________________________________
Address: _______________________________________ City/Town: _________________________________________
Telephone: (H) ___________________ leave message Y N (C) _____________________ leave message Y N
Date of Birth: ____________________ (dd/mm/yyyy) Birth Gender: Male Female Identified Gender: _________
Name of Family Physician: ______________________________ Phone Number: _______________________________
Psychiatrist: _____________________________________ Phone Number: ___________________________________
SECTION B: (if referring to multiple programs, please number priority of services)
CAPS − Centralized Access to
Psychiatric Services
Assessment
Diagnostic Clarifications
Medication Recommendations
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
Assessment
Diagnostic Clarifications
Medication Recommendations
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
Urgent Access Nurse Practitioner
(NH ED Physician Only)
Alcohol
Opiates
Other:
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
Seniors Mental Health
RAAM − Rapid Access to
Addiction Medicine
Cognitive Decline
New Mental Health
Longstanding Mental Health
Contact Person for Appointment: _____________________________________
Relationship: ____________________ Phone Number: ____________________
INCLUDE ALL RECENT LAB WORK, CT/MRI HEAD, BMD, RELEVANT CONSULTATIONS
WRICCP − Wellness Recovery
Integrated
Comprehensive
Must meet ALL the following criteria:
Recent suicide attempt
Recent / frequent ED / Admission
Inpatient
Acute phase of mental health illness
Significant impact to functioning
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
Adult Group Therapy (check one)
Depression Anxiety Bipolar Emotion Dysregulation
Schizophrenia ADHD Pain Control and Wellness
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
Day Hospital
Complex mental health
Impairments with daily functioning
GEM − Guiding Emotions Mindfully
(1.5 days per week SCS
only)
Severe emotion dysregulation
History of trauma
Medication Clinic − to complete this referral you must also go to page 3 to
input additional required information
Internal Use Only:
Reason for Referral:
Program Requested:
#____ (physician/NP referral only)
#____
#____
#____ (physician/NP referral only)
#____
#____
#____
#____
#____
Care Program
(3 days per week SCS only)
_
_
_
_
_
_
_
_
_
Rev. 12/2018 (v1)
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Page 2 of 5
Chart Copy − Do Not Destroy
Adult Outpatient Referral Form
Mental Health and Addictions
SECTION B: (Continued)
Reason for Referral: Internal Use Only:
Program Requested:
ECT − Electroconvulsive Therapy − to complete this referral, you must also go to
Page 4 to input additional required information
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
rTMS − Repetitive Transcranial Magnetic Stimulation − to complete this referral,
you must also go to Page 5 to input additional required information
CTO − Community Treatment
Order
Assess Suitability
Appt. Date: ______________
Completed: _______________
See Notes: Yes N/A
30+ days inpatient mental health
admission within past 3 years
2 lengthy inpatient mental health
admissions within past 3 years
Previous CTO in the past
SECTION C: PRESENTING SYMPTOMS:
Current challenges / concerns:
Previous / Current Mental Health Diagnosis (must indicate mild / moderate / severe as per PHQ−9): attached PHQ−9
Previous / Current Medical Diagnosis:
Previous / Current Medication(s) / Dosages:
attached medication list
Allergies: _________________________________________________________________________________________
Alcohol / Substance Use
Present
(within past 6 months)
Past
(6 months or more)
Denied Unknown
Problem
Yes No Yes No
Violent Behaviour
Suicidal Ideation
Suicidal Attempts
Self−Harming Behaviour
SECTION D: RISK Please complete the following chart:
If answered yes above, please identify / report concerns: _________________________________________________
Referring Source (print): ____________________
Referring Source Phone: ____________________
Signature: _______________________________
MD/NP Billing #: _______________________________
Referring Source Fax: __________________________
Referral Date: _______________________ (dd/mm/yyyy)
#____
#____
#____
_
_
_
Rev. 12/2018 (v1)
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Chart Copy − Do Not Destroy
Page 3 of 5
Adult Outpatient Referral Form
Mental Health and Addictions
Additional Required Information − Medication Clinic:
Please call Medication Clinic before submitting Referral Form 905−378−4647: Niagara Falls Ext. 53812
St. Catharines Ext. 46437 Welland Ext. 33402
Please fax all referrals to 905−704−4420. For any enquiries, please call Intake at 905−378−4647 Ext. 49613
Long Acting Injection (LAI):
Name and Dosage of Prescribed Long Acting Medication:
Medication Start Date:
Date Injection Last Given:
Follow Up Appointment for Outpatient Medication Clinic?
Follow Up Appointment Made for Psychiatrist / Nurse Practitioner?
Patient Aware of Medication Clinic Location?
Is Patient on Drug Plan?
Patient’s Pharmacy where drug card being used?
Clozaril® (clozapine):
Medication Start Date:
Follow Up Appointment for Outpatient Medication Clinic
Follow Up Appointment Made for Psychiatrist?
Seperate Prescription written for Clozaril® (clozapine)?
Sufficient dose until next appointment in Medication Clinic
Deliver and fill prescription prior to Discharge?
Clozaril® (clozapine) Prescription given to patient?
Patient aware of Medication Clinic location?
Please send the following information for NH referrals only: Completed referral form
Doctor’s order
Prescription
Copy of CSAN Form 1
Clinical Pathway client dicharged on
Last CBC report
Client’s history
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
CSAN Number:
Rev. 12/2018 (v1)
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Chart Copy − Do Not Destroy
Page 4 of 5
Adult Outpatient Referral Form
Mental Health and Addictions
Additional Required Information − ECT − Electroconvulsive Therapy:
Clients MUST have had a psychiatric / mental health assessment by GP, psychiatrist or NP within past 6 months.
If not, please refer to CAPS for assessment and diagnostic clarification
Please fax all referrals to 905−704−4420. For any enquiries, please call Intake at 905−378−4647 Ext. 49613
Yes No
Yes
No
Yes No
Yes No
Treatment − resistant depression
Major depressive disorder with psychotic feature
Unable to tolerate antidepressant medications
Mania non−responsive to pharmacological treatment
Acutely suicidal
Malnourished / dehydrated, rapidly deteriorating physical status
Schizophrenia − antipsychotic non−responsive
Prior ECT favourable response
Other indication for ECT
Yes No
Yes No
Yes No
Yes No
Yes No
Previous ECT details (name of institution, describe the type of ECT, if bilateral / unilateral, number of treatments,
response and any unusual side effects).
General Anaesthesia History: any complications with general anaesthetic?
Yes No
Consent: Yes No
If "No" who is the substitute decision maker / contact number? ________________________________________
Lab / Diagnostic Tests must be sent with this referral: CBC, TSH, B12, Sodium, Potassium, Chloride, Ca, Mg,
Phosphate, AST, ALT, GGT, ALP, Bilirubin, BUN, Creatinine, Fe, Urinalysis, EKG and any other relevant tests /
procedures / consultation notes
Internal Use Only:
Anaesthesia Consult: _______________ Physician Consult: _______________ First ECT: _________________
Is the person competent to consent to treatment?
Rev. 12/2018 (v1)
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Chart Copy − Do Not Destroy
Page 5 of 5
Adult Outpatient Referral Form
Mental Health and Addictions
Additional Required Information − rTMS − Repetitive Transcranial Magnetic Stimulation:
Clients MUST
have had a psychiatric / mental health assessment by psychiatrist or NP within past 6 months.
If not, please refer to CAPS for assessment and diagnostic clarification
Please fax all referrals to 905−704−4420. For any enquiries, please call Intake at 905−378−4647 Ext. 49613
Indications for rTMS:
Major depressive disorder
Potential Contraindications for rTMS:
History of epileptic seizures
History of stroke
Family history of epilepsy
History of syncopal episodes
Head trauma with loss of consciousness
Cardiac disease
Cardiac arrhythmia
Implanted cardiac pacemaker or defibrillator
Implanted DBS or other neurostimulator
Cochlear implant
Medication infusion device
Aneurysm clip or coils
Metallic implant or other foreign body
Ever have metal fragments in eye
History of metal work
History of spinal surgery
Impairment of vulnerability of hearing
History / current alcohol use
Pregnancy
Please elaborate for each "Yes" indication
Yes No
Yes No
Yes No
Yes No
Internal Use Only: Previous rTMS Previous ECT
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
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