CLIENT/PATIENT INFORMATION REFERRAL SOURCE INFORMATION
Legal name: Name:
(last name, first name)
(last name, first name)
Preferred name (if applicable):
Check one:
PsychiatristNurse PractitionerFamily Physician
Other:
Mother's maiden name: Tel:
Date of birth: Fax:
(dd/mm/yyyy)
E-mail address:
For persons 16 years and older, consent is required for assessment to be
completed. Please ensure you have spoken to the person about the referral.
Is your client/patient aware of this referral?
Address:
Yes
No
If no, please explain:
Billing number (if referred by physician):
What is your client's/patient's gender? Check ONE only:
Female
Male
Trans - Female to Male
Intersex
Prefer not to answer
Do not know
Trans - Male to Female
Other (please specify)
Is client's/patient's current psychiatrist aware of referral?
Yes
No Unknown
Does not have psychiatrist
If Yes, name of psychiatrist:
(last name, first name)
Telephone number(s) (specify home, office, cell, etc.) CLIENT/PATIENT ETHNICITY INFORMATION
Tel:
Which of the following best describes client/patient racial or ethnic group?
Tel:
Check ONE only.
If you are able to advise, please confirm if confidential messages
can be left at the numbers provided above:
Yes
No
Details:
By listing an e-mail, the referral source confirms that the client consents
for CAMH to e-mail appointment details and is aware that e-mail is not
entirely secure. CAMH will refrain from sending unrequired personal
information until e-mail addreses and consents are verified.
E-mail address:
Address:
Health card #:
Version code: Expiry date:
(dd/mm/yyyy)
Is there a need for an interpreter (e.g., for sign language or other language)?
Yes
No
If Yes, please specify:
ALTERNATE CONTACT INFORMATION (CLIENT/PATIENT OR LEGAL GUARDIAN CONSENT MAY BE REQUIRED)
Is there anyone other than the client/patient that we should
contact?
No
Yes
(last name, first name)
Relationship to client/patient:
Tel: Tel:
GUARDIAN AND CUSTODY STATUS (IF APPLICABLE)
1. Guardian name:
Joint Custody
Lives with both parents
Sole custody
Other (CAS/relative)
Client lives independently
Custody Status: (both parents
need to be aware and consenting to the assessment)
CAMH REFERRAL FORM
Date of referral (dd/mm/yyyy):
Asian - East (e.g., Chinese,
Japanese, Korean)
Asian - South (e.g., Indian,
Pakistani, Sri Lankan)
Asian - South East (e.g.,
Malaysian, Filipino, Vietnamese)
Black - African (e.g., Ghanaian,
Kenyan, Somali)
Black - North American (e.g.,
Canadian, American)
Black - Caribbean (e.g.,
Barbadian, Jamaican
First Nations - Non-status
First Nations - Status
Indian - Caribbean (e.g.,
Guyanese with origins in India)
Indigenous / Aboriginal not
included elsewhere
Inuit
Latin American (e.g., Argentinean,
Chilean, Salvadorian)
Métis
Middle Eastern (e.g., Egyptian,
Iranian, Lebanese)
White - European (e.g., English,
Italian, Portuguese, Russian)
White - North American (e.g.,
Canadian, American)
Mixed heritage (e.g., Black-
African and White-North
American) (Please specify)
Other(s) (Please specify)
Prefer not to answer
Do not know
Telephone #:
2. Guardian name:
Telephone #:
Client/Patient ID Label
(For CAMH use only)
Page 1 of 2
F0102-20141021
Chart Tab: Referral/Intake
