Fill - Free fillable Patient Information Form (City of Oakland) PDF form

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Patient Information Form

You have been referr

ed for admission to Homewood Health Centre. To prepare for your arrival, we need some

information from you. If you are unable to complete this form by yourself, you can ask a friend or relative to help you

complete it, or you may phone Homewood’s Admitting Department for assistance.

Please comp

lete this form

in black ink and return it to:

Admitting Department - 150 Delhi Street, Guelph ON N1E 6K9

Phone: 519.824.1010 Fax: 519.767.3533 Email: admit@homewoodhealth.com

PATIENT CONTACT INFORMATION Please provide telephone number(s) where messages can be left

Today’s Date: Title: Last Name: Given Name:

Preferred Name: Middle Name: Alias:

Preferred Pronouns: Gender Identity: Biological Sex: Date of Birth:

Address:

No current address

City:

Province/State: Postal/Zip Code: Country:

Home Phone: Business Phone: Ext: Cell phone:

Email: Preferred Method of Contact: Home Phone Cell Phone Email

Health Card Number: Version Code: Issuing Province:

Health Card Name (if different from above): or reason for no HC#:

TREATMENT PROVIDER INFORMATION

Referring Physician/Clinician: Disability Case Worker:

Family Physician: Phone:

Address:

PATIENT INFORMATION

What type of accommodation are you requesting? Ward Semi-Private Private

Why have you been referred for a Homewood admission?

For this admission to be successful, what do you want to see happen or change?

Please list any allergies (e.g., medication, foods, insects):

Are you pregnant?

Yes No

If yes, when are you due:

Are you currently involved in a clinical drug study/trial?

Yes No

If yes, explain:

Have you had a flu shot in the last year?

Yes No

If yes, please bring documentation of this

Your height: Your weight:

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SAFETY QUESTIONS

Do you have a history of:

Yes No

Falling?

Yes No

Suicide attempts?

Yes No

Fire setting?

Yes No

Violence towards property?

Yes No

Self-harm (e.g. cutting, burning, etc.)

Yes No

Violence towards others?

Yes No

Sexual aggression?

Yes No

Wandering or leaving hospital without permission?

No Yes

Currently are you able to maintain the safety of yourself and others in an unlocked hospital setting without

constant supervision?

Additional comments:

GROUP READINESS AND FUNCTIONING

No Yes

Are you fluent in English? If no, other preferred language:

Yes No

Are you limited in your ability to walk? If yes, you may wish to bring a cane, walker, wheelchair or electric

wheelchair.

Yes No

Do you require our assistance to

participate in group programming

due to significant limitation of

your vision or hearing?

How can we help?

Yes

Do you plan to bring a service animal?

SUBSTANCE USE HISTORY

No Yes

Some Homewood programs require supervised urine drug testing. Do you agree to urine drug testing if ordered

by the Homewood physician?

Yes No

Do you use tobacco products (e.g. smoke)?

Yes No

Do you use medical marijuana?

Yes No

Do you take methadone? If yes, amount used daily:

For addiction or chronic pain

Yes No

Do you take suboxone? If yes, amount used daily:

For addiction or chronic pain

Yes No

Do you use alcohol or any addictive substance? If yes, please fil out the following table:

Date of last use? Amount used per day? Date of last use? Amount used per day?

Alcohol Opiates

Cocaine Other:

Marijuana Other:

LEGAL QUESTIONS

Yes

Are you facing any criminal charges currently? If yes, please describe:

Yes

Is your treatment court mandated (required by a court order)?

Yes No

Do you have any upcoming court appearances scheduled

to testify, defend against charges or receive sentencing?

If yes, when?

Yes No

Are you currently on probation?

Yes No

Have you ever been found NCR (Not Criminally Responsible)?

Yes No

Do you have a criminal record? Please describe:

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PAST ADMISSIONS

Yes

Have you had a previous admission to Homewood and/or other psychiatric or addiction facilities?

If yes, please list any admissions:

Year Admitted: Facility: Length of Stay:

Number of admissions to Homewood: Number of admissions to other facilities:

CURRENT TREATMENT

Are you currently using any out-patient services? Yes No If yes, please provide details:

Name of Service: Contact: Telephone:

Are you currently participating in any self-help groups? Yes No

If yes, please list:

CURRENT EMPLOYER

Name: Phone Number:

Address: City:

Province/State: Postal/Zip Code: Country:

EMERGENCY CONTACT INFORMATION Please provide telephone number(s) where messages can be left

Name: Relationship to Patient:

Address: City:

Province/State: Postal/Zip Code: Country:

Phone: Alternate Phone: Email:

NEXT OF KIN CONTACT INFORMATION Please provide telephone number(s) where messages can be left

Same as above, if not complete below:

Name: Relationship to Patient:

Address: City:

Province/State: Postal/Zip Code: Country:

Phone: Alternate Phone: Email:

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PHARMACY INFORMATION

Pharmacy Name: Phone:

Address: City:

Province/State: Postal/Zip Code: Country:

Have you used another pharmacy in the last year? Yes No Unknown

DRUG PLAN INFORMATION

Do you have a drug plan? Yes No

If no, how do you currently pay for drugs?

Please note: for ODSP, Trillium and other Ontario Government social service programs, there is an online list that your

Homewood doctor can consult to ensure the prescribed medications are covered.

BILLING

If you are requesting semi-private or private accommodation, please complete this section:

Are you self-paying for your accommodation? Yes No

If you are self-paying (in part or in whole), please indicate the method of payment: Cash Major Credit Card Cheque

If you are not self-paying, please provide the following information:

Name of Payer: Phone:

Address: City:

Province/State: Postal/Zip Code: Country:

Note: 30 days’ payment is due on the date of admission. Please refer to financial information provided by the Admitting Department.

INSURANCE INFORMATION

Note: Please forward a copy of your benefit card.

Primary Insurer:

Name of Insurance Company: Employee Number:

Group Policy Number: I.D. or Certificate Number:

Subscriber’s Name: Subscriber’s Date of Birth:

Subscriber’s Employer: Subscriber’s Phone Number:

Subscriber’s Address (if different):

City:

Province/State: Postal/Zip Code: Country:

Patient’s Relationship to Policy Holder: Holder Spouse Dependant Student (full-time) Student (part-time)

Secondary Insurer:

Name of Insurance Company: Employee Number:

Group Policy Number: I.D. or Certificate Number:

Subscriber’s Name: Subscriber’s Date of Birth:

Subscriber’s Employer:

Subscriber’s Phone Number:

Subscriber’s Address (if different):

City:

Province/State: Postal/Zip Code: Country:

Patient’s Relationship to Policy Holder: Holder Spouse Dependant Student (full-time) Student (part-time)

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Although you may have semi-private or private coverage, you should be aware that some insurance companies do not cover

accommodation at Homewood Health Centre Inc. To avoid unexpected charges, we strongly suggest that you obtain written verification

that your insurance company will cover the cost of your stay at Homewood prior to admission. Please note: you are responsible for

payment of your semi-private or private accommodation if your insurance company does not cover the cost.

Please ask your insurance company the following questions:

1. Does my insurance cover the cost of semi-private or private accommodation for mental illness/addiction treatment at

Homewood Health Centre Inc.?

2. What is the maximum amount of money or maximum length of stay covered by my insurance?

Our practice with some insurance companies is to email information for verification. Please contact us if you are not in agreement with

this process. Please sign below authorizing Homewood to verify the accuracy of the above insurance information with your

insurance company and/or employer (Note: when verifying this information with the insurance company, it may be necessary to

share the reason for admission).

Please note that Homewood Health offers a comprehensive continuum of care that focuses on mental health and addiction

inpatient and outpatient treatment. If one of our services beyond the Homewood Health Centre is deemed beneficial to meet

your needs, we will have intake from the appropriate Homewood Health service connect with you about all Homewood Health

has to offer.

Signature: Date:

Homewood is compliant with current privacy legislation. Homewood collects personal information for assessment and treatment, as well

as for operational and organizational, research and teaching, and legal and regulatory purposes. For questions or concerns contact the

Privacy Office at privacy@homewoodhealth.com or 519.824.1010, extension 32443.

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Version: August 19, 2020

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Treatment at Homewood Health Centre during COVID-19

The health, safety and wellbeing of our patients, staff and volunteers is Homewood Health’s

priority. We have put the following measures in place for everyone’s protection.

14 DAY ADMISSION RESTRICTIONS:

 You will be given a wristband to wear at all times for your first 14 days of treatment

 During this time, you will not be able to use the Recreation Centre, fitness or yoga rooms,

gymnasium, Library or patient dining room except during scheduled program use

(Horticulture Therapy, Creative Arts, Recreation Therapy in the gymnasium etc.)

 Your meals will be delivered to your unit for you to eat in your room or in your unit’s

common area

MASK USE:

 You are required to wear a mask at all times throughout your admission (including when

you are in our fitness and yoga room)

 The only exceptions are:

o When you are outside on the grounds and are able to physically distance from

others by at least two meters (six feet)

o When you are in your own room and are able to physically distance from your

roommate (if applicable), and when you are asleep

GROUNDS PRIVILEGES:

 You are limited to grounds privileges only which mean that you are not to leave

Homewood’s property for the duration of your admission

 Doing so may result in your immediate discharge

VISITORS:

 You may designate one visitor (over the age of 18) for the duration of your admission

o This person will remain your designated visitor throughout your treatment; your

designated visitor cannot be changed

 Visitors will be scheduled for pre-arranged, one hour visiting time slots on dedicated days

o We are not able to accommodate last minute visits or “walk-ins”

 Scheduled, one-hour visits will take place on the unit only

 The visitor will be asked to show photo ID at the entrance and will be screened, including

a temperature reading, before they enter for each visit

 You and your visitor must be wearing masks throughout the visit

 Physical distancing (six feet/two meters apart) must be maintained at all times, including

between you and your visitor

 Any packages being brought in by visitors will be checked to ensure contents comply with

our safety policies

 A reminder that outside of scheduled visits with your designated visitor, there are

still no unscheduled visits permitted. An unscheduled visit is any in-person interaction

(regardless of whether any physical contact is made) with someone who is not currently

on active duty affiliated with the work of Homewood, is not a current patient admitted to

or actively participating in the services of Homewood, and is not your designated visitor

during an on-unit, scheduled visit. If you are in breach of Homewood’s visitor policy

you may have your 14 day admission restrictions re-started (if applicable), restricted

to your unit and discharge may be considered.

PACKAGE DELIVERIES:

 You are asked to limit your package deliveries to four (4) deliveries per admission

 Packages are processed by our loading dock Monday to Friday – you will not be able to

retrieve your package directly from the loading dock

 All packages delivered will be opened under supervision of a staff member to

ensure the contents are complying with our safety policies

Version: August 19, 2020

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DROP OFF OF ITEMS:

 Your friends and family are able to drop off items for you to a member of our

screening team via the Delhi Street entrance

 You parcel will then be kept in a locker until you and a member of your care team can

retrieve it and checked to ensure the contents are complying with our safety policies

 A reminder that this is not an opportunity to visit and doing so will be considered a

breach of our visitor policy

FOOD DELIVERIES:

 If you order food to the Health Centre via a delivery service, please pre-pay, wear your

mask when you retrieve your food and maintain physical distance from the delivery

person

 Your food deliveries may be inspected at the discretion of your care team

OFFSITE APPOINTMENTS:

 If you are approved to leave Homewood grounds for an appointment offsite (i.e. a

medical appointment), you will need to wear a mask

 Upon return to Homewood, the 14 day admission restrictions outlined above will

restart and you will be provided with a new wristband (if applicable)

This document is subject to change as we continue to monitor COVID-19 and we are taking the

precautions outlined above extremely seriously. They are in place to limit the risk of exposure to

the COVID-19 virus and protect our patients, your loved ones and our staff.

Thank you in advance for your cooperation.

I have read and understand the above and I agree to comply with all outlined guidelines

in this document throughout my admission. I acknowledge that these guidelines may

change during my treatment and that I will follow direction of Homewood Health Centre

staff on these and any other matters related to the COVID-19 pandemic.

I also understand that any breach in the above guidelines may result in consequences,

potentially including restarting my 14 day admission restrictions, limiting my privileges

to my unit only, or discharge from my program and Homewood Health Centre.

_____________________________ _____________________________

Patient Signature Witness

_____________________________

Date

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