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University of Guelph Student Wellness Referral Form for External Use
Fax completed referral to Health Services: (519) 821-2308
Purpose of This Form: We are committed to arranging appropriate and timely follow-up
for University of Guelph students, however please know that there is often a waitlist for
services. The information on this form will be used by us to internally triage all referred
students to appropriate internal resources at the University as soon as possible.
Referral Date:
Student/Patient Information:
Legal Name:
Preferred Name:
Referral Source Information:
Name:
(last name, first name)
Family Physician Psychiatrist
Other MD Nurse Practitioner
Lives on campus in residence?
Y N
Current Address:
Telephone:
Fax:
Address:
Billing #:
Date of Birth (dd/mm/year):
Will you be providing follow-up with
this person until they are seen?
Y N
If not, please explain plan:
Telephone Number:
Health Card #:
Does the student consent to this referral? Y N
If so, please ensure to attach relevant notes
Is the student known to Counselling Services? Y N
If so, who?
Is the student known to our Student Health Services physicians and/or psychiatrists?
Y N If so, Who? ____________________________________
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REASON(S) FOR REFERRAL:
Follow-up regarding Medical Presentation
Follow-up regarding Mental Health Presentation
CURRENT PRESENTING CONCERNS (Symptoms, current problems, why are you
referring the student to the University of Guelph now?):
Please Specify Identified Risks:
Risk Issue
Check
If Yes, when?
Details
Past suicide attempt(s)
Y N
Suicidal Ideation
Y N
Family history of suicide
Y N
Deliberate self-harm
Y N
Hospitalizations (recent)
Y N
Recent ER visits
Y N
Current psychotic symptoms
Y N
Problematic substance use
Y N
Aggression/violence
Y N
Legal involvement
Y N
Fire setting
Y N
High risk behaviours (specify)
Y N
Other (please specify)
Y N
RELEVANT PSYCHOSOCIAL CIRCUMSTANCES Please include any personal
history or current life circumstance of note (e.g. sexual assault, family dynamics,
life events):
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RELEVANT MEDICAL HISTORY/PSYCHIATRIC DIAGNOSES:
CURRENT MEDICATIONS:
Medications
Dose/Frequency
HOSPITALIZATIONS, THERAPIES, AND SERVICE INVOLVEMENT FOR THE PAST
2 YEARS:
IS THIS REFERRAL FOLLOWING A CURRENT HOSPITAL ADMISSION: Yes No
Discharge date:
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Discharge Summary Attached: Yes SSAU Assessment Attached: Yes
Reason for Current Admission:
ACCESSIBILITY SERVICES:
Does the student require academic accommodations related to a disability, including
mental health, which is either temporary or permanent? Yes No
If Yes, please complete a functional assessment form at www.uoguelph.ca/sas and fax
to 519-824-9689.
ADDITIONAL INFORMATION:
Signature (name and credentials)
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