Fillable Referral Form for Treatment (City of Oakland)

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Referral Form for Treatment (City of Oakland)

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Referral Form for Treatment
Date of Referral:
Thank you for referring your patient to Homewood Health (HH). HH offers a comprehensive national continuum of care that
focuses on mental health and addiction inpatient and outpatient treatment. If one of our services is outside of your patient's
preferred treatment location, or you are unsure of the recommended facility for treatment, please indicate "unknown" in section 1
below and we will consult with your patient to help determine the appropriate Homewood Health location.
Section 1: P
referred Referral Location
Inpatient Outpatient
Homewood Health Centre – Guelph, Ontario
The Homewood Clinic – Vancouver, British Columbia
The Homewood Clinic – Edmonton, Alberta
The Homewood Clinic – Calgary, Alberta
The Homewood Clinic – Mississauga, Ontario
Unknown
Section 2: Client/Patient Information
Client/Patient Name:
Gender:
Address:
City:
Province/State: Postal/Zip Code: Country:
Date of Birth:
Email Address:
Home phone: Mobile Phone:
Current height: Current weight: Allergies:
Occupation: Employer Name:
Health Card #:
Expiry Date:
Department of National Defense Blue Cross Service # (if applicable):
Veterans Affairs Canada K # (if applicable):
Workers Compensation Board # (e.g., WSIB, Worksafe BC):
Section 3: Primary Reason
for Referral & Return to W
ork Goal (if applicable)
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Room Accommodation: Semi-Private
Private
Note, assigned accommodation is based on funder/referring agency approval.
Ravensview – Victoria, British Columbia
The Residence – Guelph, Ontario
I am interested in learning about Homewood delivered Recovery Management post-
inpatient treatment that may be
available in my province/territory.
Yes
No
Section 1a. Recovery Management ('aftercare') through Homewood
Reset Form
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Section 5: Current Safety Risks (Check all which apply)
History of fire setting
History of suicide attempts
Date of last attempt:
History of violence towards self (self-harm)
History of violence toward others or property
Risk of falling, history of recent falls
Current active suicidal thoughts
Current legal issues
/ past legal issues
Current passive suicidal thoughts
Current thoughts of harm to others
Dissociation
Flashbacks
Wandering / AWOL risk
Please provide additional details regarding risks identified above:
Section 6: Post-discharge Care Provider
Name:
Address:
City:
Province/State: Postal/Zip Code: Country:
Email: Phone: Fax:
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Section 6a: Post-discharge Community Care Provider (non-
Homewood)
Name:
Address:
City:
Province/State: Postal/Zip Code: Country:
Email: Phone: Fax:
Section 4: Conditions
(Check all which apply and indicate which is the primary concern)
In the
last 6
months
Prior to 6
months
ago
Primary
Concern
In the
last 6
months
Prior to 6
months
ago
Primary
Concern
Acute or Chronic Psychosis
(Thoughts disorder/hallucination/delusion)
Addiction
(drug and/or alcohol)
Dissociative Disorder
Eating Disorder
ADHD
PTSD, Abuse, Trauma or OSIs
(Occupational Stress Injuries (OSI))
Major Depression (Unipolar)
OCD (Obsessive Compulsive Disorder)
Bipolar Disorder (Hypomania, mania, depression)
Personality Disorder
Schizophrenia
Substance Abuse (drug and/or alcohol)
Anxiety Disorder (Social Phobia or panic disorder)
Autism or Autism S
pectrum Disorder
Chronic Pain
Cognitive Disorder (Head injury,
memory problems)
Dementia
Other (please describe):
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Section 11: Current Medications
1. List here or attach a list (using the format below) of all current medications and supplements:
Name Dosage Frequency Reason for Use
2. Does the client/patient take prescribed opiates? (e.g., codeine, Methadone etc.) Yes No
If yes, for pain, for addiction.
Section 12: Significant Medical History
List all applicable conditions (e.g., diabetes hypertension, etc.)
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Section 8: Referral Information
In order to arrange a timely admission to the most appropriate program, please provide us with clinical information from
the past 6 months. Copies of past consults, test results and discharge summaries are very helpful.
Referral documentation attached: Medication List Consent Forms Other:
Is this patient an urgent referral? Yes No Is the patient aware of the referral? Yes No
Section 9: Recent Admissions
1. Has the patient had any psychiatric and/or medical hospitalizations within the last 5 years? Yes No
If yes, Where: When: Why:
Please forward discharge notes or consults from hospital stays
2. Is the patient currently in a hospital? Yes No
If yes, Where: Date of admission:
3. Is their current status involuntary? (certified inpatient) Yes No
4. Has the patient tested positive for: C-Difficile MRSA VRE
Section 10: Group Ready
No Yes Is the patient able to participate in a group based program?
No Yes Is the patient able to reside on an unlocked unit?
Yes No Does the patient have a substitute decision maker?
Yes No Is the patient subject to a Community Treatment Order (CTO)?
Section 7: Referrer Information
Your Name:
Your Health Care Discipline (e.g. Family Medicine, Social Worker):
If applicable, Physician/NP Billing #:
If applicable, Agency (ex. WSIB, DND, VA):
Address:
City:
Province/State: Postal/Zip Code: Country:
Email: Phone: Fax:
If you are from a Health Care Discipline, will you provide this patient care after discharge?
Yes
No
Section 13
: Addiction
1.
Does the patient currently
have any drug or alcohol (substance) pr
oblem
s?
Yes No If no, skip to section 14
First substance of choice is:
Years of use: Amount used per day:
Second substance of choice is:
Years of use: Amount used per day:
2. Has the patient ever experienced severe withdrawal symptoms from alcohol or drugs (e.g., DTs, psychosis, seizures or
hallucinations)? Yes No If yes, describe:
3. Does the patient admit to having a drug or alcohol problem? No Yes
4. Is the patient currently prescribed the following medications? Note: some programs have specific admission requirements
concerning methadone treatment.
Dosage: Prescribed for: Comments:
Methadone
No Yes mg/day
addiction treatment
chronic pain management
Suboxone
No Yes mg/day
addiction treatment
5. Is the client/ patient using medical marijuana?
chronic pain management
Yes No Comments:
6. Does the client/patient use nicotine? Yes No Comments:
Please note, all inpatient facilities are tobacco free
Section 14
(if applicable):
If you are referring to the Eating Disorders Program at Homewood Health Centre additional information will be needed.
Forms will be forwarded to the patient.
If you are referring for Traumatic Stress Recovery, please indicate all the types of trauma the client/patient has experienced:
Violence Accident Occupational Military Childhood Other:
Thank you for your referral to Homewood Health
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All forms and copies of past records and reports should be sent as soon as possible to:
Fax: 1.855.895.0666 or Email: treatment@homewoodhealth.com
We will contact you once a decision has been made regarding your patient’s admission. If you have any questions, please
contact our Intake Consultants at 1.866.221.0237. We are available Monday through Friday from 9:00 AM to 10:00 PM EST,
and Sunday from 1:00 PM to 9:00 PM EST (excluding statutory holidays) .
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Referral Form for Treatment (City of Oakland)

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Completed 27 July 2021

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