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North Bay Regional Health Centre (Collège Boréal)

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North Bay Regional Health Centre
Regional Mental Health
Referral Form
Complete form online, print, and
fax to 705-476-6136
Phone 705-476-6240 ext. 6294
Website: www.nbrhc.on.ca
RHC 817 Revised September 2021 watsoc Page 1 of 4
*Please Note: We are not a crisis or emergency service. If your patient requires immediate attention and
cannot wait for an assessment, please consider accessing the local emergency department.
**Please Note: Incomplete referrals will result in a delay as we cannot make a decision until all information is
received.
Client Information Health Link Client
Yes No
Last Name First and Middle Name
Health Card Number Version Expiry Date
(dd/mmm/yyyy)
Date of Birth (dd/mmm/yyyy) Gender
Female Male Other
Marital Status
Current Address
City Province Postal Code
Home Phone Work Phone Cell Phone
Preferred Language First Language
Housing
Private Home/Apartment
Long-Term Care Facility/Retirement Home
Setting for person with intellectual disability
Setting for person with physical disability
Mental Health Residence
Supportive (Board and Care)
Correctional Facility
Hospital
Other (describe):
Family/Caregiver/Next of Kin Information
Last Name First Name
Address City
Postal Code Phone Cell
Relationship
Is this person identified as Substitute Decision Maker (SDM)?
Yes No NA
Capacity to Consent
Client/SDM Agreeable to Referral
Yes No
Client/SDM Consents to Referral
Yes No N
A
Capacity to Consent to Treatment
Yes No N
A
Capacity to Consent to Collection/Use/Disclosure of Personal Health Information
Yes No N
A
Capacity to Consent to Manage Property/Finances
Yes No N
A
Mental Health Status
Voluntary
Involuntary Form # Expiry Date Contesting Involuntary Form
Yes No
dd/mmm/yyyy
Community Treatment Order Expiry Date
dd/mmm/yyyy
Click Dropdown Arrow to Select
Client Name: __________________________________ NB#: __________
RHC 817 Revised September 2021 watsoc
Page 2 of 4
Criminal Legal Status
Charges Pending (for):
On Probation (for):
Probationary Restrictions:
Substitute Decision Maker/Power of Attorney (complete only if different from Next of Kin)
Last Name: First Name:
Address: City:
Postal Code: Phone: Cell:
Relationship:
Reason for Referral
Factors Contributing to Referral (precipitating event, current symptoms, and level of urgency): Max 300 characters
Psychiatric Diagnosis(es) both known and suspected: Max 300 characters
Medical Diagnosis/Active Treatment (please include active treatment i.e., IV): Max 300 characters
Risks
Harm to Self
Harm to Others
Medication Non-adherence
Suicide
Sexual Aggression
Wandering/Elopement
Choking/Aspiration/Dysphagia
Living Alone
Arson/Fire Setting
Weapons
Eating Disorders
Alcohol Misuse
Drug Misuse
Tobacco/Nicotine Use
Falls
Community Supports Prior to Admission
Have district resources been optimized?
Yes No
Last Name: First Name:
Agency Name:
Address: City:
Postal Code: Phone: Fax:
Outcome of Interventions:
Last Name:
First Name:
Agency Name:
Address: City:
Postal Code: Phone: Fax:
Outcome of Interventions:
Client Name: __________________________________ NB#: __________
RHC 817 Revised September 2021 watsoc
Page 3 of 4
Preadmission Goals
Client’s Goals for Admission: Max 300 characters
Family’s Goals for Admission: Max 300 characters
Referent’s Goals for Admission: Max 300 characters
Service Specific Documentation Required (please attach current reports)
Dual Diagnosis (Birch/Maple): Psychiatric Rehabilitation (Nickel/Northern):
Medication List
Medication List
Psychiatrist Notes/History
Psychiatrist Notes/History
Medical Assessments/Consultations
Medical Assessments/Consultations
DSO/Supports Intensity Scale
Geriatrics (Evergreen/Oak):
Medication List
Recent Cognitive Screening (MMSE, MoCa, etc.)
Psychiatrist Notes/History
Recent BSO PIECES Summary and Assessments
(RAID, CMAI, GDS, etc.)
Medical Assessments/Consultations
Delirium workup (Labs and Urine)
Care of the Elderly/Geriatrician/Geriatric Psychiatrist
Consultation Note
Referring Physician
Full Name: CPSO#:
Phone: Fax:
Full Name of Primary Care Provider :
Phone: Fax: Aware of Referral?
Yes No
Referral Completed By
Name:
Agency:
Phone: Fax:
Signature: Date:
Do you have access to videoconferencing?
Yes No
dd/mmm/yyyy
Complete and fax to 705-476-6136 or phone 705-476-6240 ext. 6294 Website: www.nbrhc.on.ca
Click to Save As
Click to Print, then Sign Form
RHC 817 Revised September 2021 watsoc
Page 4 of 4
Appendix
Ensure you have completed all sections and attached all required documents. Additional information may be
requested after the patient is accepted for admission, but prior to attending NBRHC.
Note: This interactive online form will create a printable PDF only. When completed you will need to save
the resulting PDF file and/or print it. Signatures will be required prior to faxing to the North Bay Regional
Health Centre – Central Referral. Completed referrals are NOT to be emailed; fax to 705-476-6136. If you
require additional information regarding the referral process, call 705-476-6240 ext. 6294. The office is open
5 days a week from 8:00 a.m. to 4:00 p.m. (excluding statutory holidays).
NBRHC is Tobacco Free as of November 1, 2017. More information can be found on the NBRHC website at:
English – http://www.nbrhc.on.ca/tobacco-free/
French – http://www.nbrhc.on.ca/fr/sans-tabac/
Regional Inpatient Programs and Services that utilize this referral form are the following:
Birch/Maple Lodge
Dual Diagnosis Unit
14 bed unit
Age:18+
Service Area: North East Region
Referrals Accepted from: Psychiatrist, Primary Care provider
Type of Service: Developmental/intellectual disability plus mental health
concerns/behavioural challenges focus on the specialized needs of those
functioning in the moderate to profound range of developmental disabilities.
Services include providing assessment, stabilization, rehabilitation, transitional
support to return “home”.
Nickel Lodge
Psychiatric Rehabilitation
16 bed unit
Sudbury campus
Age: 18+
Service Area: North East Region
Referrals Accepted from: Psychiatrist, Primary Care provider
Type of Service: Provides assessment, treatment, and rehabilitation for
individuals with complex and persistent mental health problems. Following
discharge, consultative services are provided by a Transitional Nurse. Nickel
Lodge also supports individuals experiencing substance use disorders concurrent
to a serious and persistent mental health concern; specific programming is
available for these individuals.
Northern Lights
Lodge
Psychiatric Rehabilitation
16 bed unit
Age: 18+
Service Area: North East Region
Referrals Accepted from: Psychiatrist, Primary Care provider
Type of Service: Provides assessment, treatment, and rehabilitation for
individuals with complex and persistent mental health problems. Following
discharge, consultative services are provided by a Transitional Nurse.
Evergreen Lodge
Geriatric Psychiatry
12 bed unit
Age: 65+
Service Area: North East Region
Referrals Accepted from: Psychiatrist, Primary Care provider
Type of Service: Provides comprehensive specialized assessment and
treatment for older adults with complex age-related psychiatric needs that may
be complicated by behavioural and psychological symptoms, and/or medical
comorbidities.
Oak Lodge
Dementia Care
18 bed unit
Sudbury campus
Age: 65+
Service Area: North East Region
Referrals Accepted from: Psychiatrist, Primary Care provider
Type of Service: Provides comprehensive specialized assessment/treatment of
older adults and/or adults with age-related dementia complicated by behavioural,
psychological and/or neurocognitive impairments that exceed capacity of
community resources.
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North Bay Regional Health Centre (Collge Boral)

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Completed 10 December 2021

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