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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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Reset Form
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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
No
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
No
Are you facing any criminal charges currently? If yes, please describe:
Yes
No
Is your treatment court mandated (required by a court order)?
Yes No
Do you have any upcoming court appearances scheduled
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
No
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