Southeast Ontario Addictions & Mental Health Services Access Form
AMHS-KFLA
This form is to be completed by Primary Health Care and other Health Services Providers
FIELDS MARKED WITH AN * ARE CONSIDERED MANDATORY AND MUST BE COMPLETED OR
REFERRAL WILL BE RETURNED AS INCOMPLETE
A GP or NP GENERATED REFERRAL FORM THAT CAPTURES ALL OF THE MANDATORY DATA WILL BE ACCEPTED
Telephone: 613-544-1356 or 613-354-7521 Fax: 613-544-2346
CLIENT INFORMATION
Date of Referral: / /
dd mm yyyy
SERVICES
What service(s) would you like your patient /
client assessed for?
Psychiatry (*PHYSICIAN and NP REFERRALS ONLY)
*Physician/NP Name:
*Physician/NP Billing #:
*Address:
*Phone:
*Fax:
________________________________
Mental Health Support Services
Addiction Support Services
Clinical Counselling
Housing
Vocational
Gambling
Eating Disorder
Other:
REFERRAL AGENT INFORMATION
(if other than Physician or NP)
*Agency / Source:
*Contact Person:
*Telephone:
*Fax:
*Name:
*Gender:
*Address:
*Telephone (home):
*Email Address:
*Date of Birth: / /
dd mm yyyy
*Health Card # & V.C.:
(or affix label above)
*BEST way to contact patient/client:
Phone Text Email Mail
*Alternate contact person:
*Name:
*Relationship:
*Phone #:
*Can a detailed message be left? Y N
________________________________
Substitute Decision Maker (personal health):
Name:
Address:
Telephone Number:
What is your patient’s mother tongue?
English French Neither
Interpreter Required? Y N
If neither, in which of Canada’s official languages is
your patient most comfortable using? Receiving health
care services in?
English French
REASON FOR THE REFERRAL: (How can we help?)
PLEASE ATTACH ANY RELEVANT INFO (Psych Notes, Meds etc.)
