Download McMaster Regional Mood Disorders Program

St. Joseph’s Healthcare Mood Disorders Program
St. Joseph’s Healthcare
Centre for Mountain Health Services
100 West 5th, Box 585
Hamilton, ON L8N 3K7
MR# _______________________________
Phone: (905) 522-1155 extension 36236
Fax: (905) 381-5616
PLEASE READ BEFORE COMPLETING (Please Print):
 Our primary mandate is to provide expert consultation for patients with diagnosed or suspected mood disorders.
 Typical consultation requests are for diagnostic clarification, treatment recommendations or for both.
 To ensure accessibility and efficient use of psychiatric resources, the service emphasizes expert consultation with
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implementation of recommendations in the community. Consultants will provide diagnostic assessment and specific
treatment recommendations. Thereafter consultants may be contacted by phone or patients referred for re-consultation.
Legal charges pending is an exclusionary criterion.
Active substance abuse makes assessment for mood disorders difficult. These patients will be seen provided that they
are also in treatment for substance use.
In order for this referral to be processed, the referring physician must sign and provide their billing number.
Please note that because of the volume and complexity of patients referred to our clinic, we cannot assume any
medical or legal responsibility for their healthcare while they are waiting for consultation.
Patient’s Last Name: ______________________
First Name:
Initial:
Address (number & street):
City:
Postal Code:
Telephone: (H)
(W)
OHIP Number: _________________________ V.C.____ Date Of Birth ______________ Age:
D/M/Y
Gender: Male
Female
Marital Status:__________________ Is patient employed? ( )Yes (
)No
Referring Physician: _______________________ Are you affiliated with a Hamilton FHT?
Address:___________________________________________________________________________
Telephone:
Fax number:
PHYSICIAN’S SIGNATURE:
BILLING NUMBER:
Reason for Referral (check all that apply):
[ ] Diagnostic Clarification
[ ] Treatment Recommendations
[ ] Cognitive Behavioural Therapy
[ ] Electroconvulsive Therapy (ECT)
[ ] Repetitive Transcranial Magnetic Stimulation (rTMS)
[ ] Other: __________________________
For Mood Disorders Program use only:
Date referral received:
Date of MDP consultation
Time:
d
m
MDP Consultant
y
March 2010
Current Problem (check all that apply):
Mood Disorder:
Other:
[ ] Depression
[ ] Hallucinations or delusions (past or present)
[ ] Bipolar Disorder
[ ] Suicide attempt(s) (when?
Anxiety Disorder:
[ ] Currently has suicidal ideation
[ ] Social Phobia
[ ] Substance abuse (alcohol, drugs, medication)
[ ] Panic Disorder with or without agoraphobia
[ ] Eating Disorder
[ ] Obsessive Compulsive Disorder
[ ] Personality Disorder
[ ] Generalized Anxiety Disorder
[ ] Current or past legal problems/history of violence
[ ] Other Anxiety Disorder _________________
[ ] Other __________________________________
)
Which of these is the most disabling problem currently? ______________________________
Brief description of current problem (attach report if available)
Recent Medical History and Family History (send copies of most recent laboratory tests/investigations e.g. thyroid):
Current Medications
Past Medications
______________________________
__________________________________
______________________________
__________________________________
______________________________
__________________________________
______________________________
__________________________________
Is this patient currently in treatment with a mental health professional? ( ) Yes ( ) No
Have they been an inpatient or had other relevant mental health assessments (E.g. neuropsychological testing and
general psychiatric) ( ) Yes ( ) No
If yes, please attach discharge summaries and all relevant consultation notes that are available. This
information is essential for a more thorough and efficient consultation.
March 2010