Rev. 12/2018 (v1)
REF41
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)