Download Central Intake Referral Form

Central Intake Referral Form
Please return the completed referral form by:
•Fax: 613.798.2976 or Mail to: The Royal Central Intake Office, 1145 Carling Ave. Ottawa, Ontario K1Z 7K4
Please contact The Royal at 613.722.6521 ext. 6211 or by email at [email protected] if you have any questions.
Your referral will be triaged to the most appropriate program based on the information provided. If your client would
not benefit from one of our programs, alternative treatment recommendations will be provided. Please complete all
required fields to prevent delays in processing/triage of your referral.
PATIENT INFORMATION
Date of referral:
Name:
Email Address:
Address:
Date of Birth: DDMMYY
/
/ Age:
Telephone No.: (Home)
Sex: q Male
q Female
(Work)
Patient’s Preferred language: Marital Status:
(Cell)
q English OHIP #
q French q Other
Secondary Insurance:
Third Party/Other Insurance:
TO BE COMPLETED BY THE REFERRING PHYSICIAN
Name:
Address:
Postal Code:
Email Address:
Telephone No.: Physician’s Private Line: Are you a:
q Family Physician
Fax No.:
(Only to be used by The Royal for questions/feedback regarding submitted form)
q Psychiatrist
q Other:
Will you continue to care for this patient once he/she has been discharged from our program?
q Yes
q No
If not, who will assume care for patient upon discharge? Please provide contact info below:
Name of care provider:
Phone No. or email address of care provider:
Is the patient aware of and in agreement with this referral?
q Yes
q No
Patient is aware that we will obtain past reports from hospitals/mental health agencies
February 10, 2014
q Yes (complete attached Schedule A)
q No
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Name:
Date of Birth:
REASON FOR REFERRAL – Please refer to The Royal’s website for a description of each program
Please check one of the following boxes to indicate the program most appropriate for your client.
Note: checking a box does not result in automatic admission to that program.
q Consult Clinic (Consultation Only)
q Mood & Anxiety
q Schizophrenia
Consult Clinic Only:
Please specify the type of treatment recommendation(s) requested:
q Community Resources q Diagnostic Clarification
q Medication Recommendations
Note: clients residing outside of Ottawa, and within the Champlain region, will be offered their consultation via
telemedicine (OTN).
Research The Royal is a teaching hospital affiliated with the University of Ottawa Institute of Mental Health Research.
Please check one of the following boxes to indicate if your patient agrees to being contacted to discuss current
research studies q Yes
q No
Please describe your clinical questions as specifically as possible.
SYMPTOM PROFILE
Mood Symptoms
q Depressed Mood
q Elevated Mood Anxiety Symptoms: q Panic Attacks q Social Anxiety
q Post Traumatic Stress
Please describe:
q Generalized Anxiety
q Obsessions / Compulsions
Please describe:
Psychosis
q Irritability
q Delusions
q Hallucinations q Negative Symptom
q Disorganized Speech / Behaviour
Please describe:
Other
Please describe:
February 10, 2014 2/3
Name:
Date of Birth:
MEDICATIONS
Current Medication (s)
Dose
Frequency
Date Started
Past Medication (s)
OTHER RELEVANT INFORMATION
Please attach previous consultations, reports and/or lab results from health care providers other then The Royal
Current Substance Use? (Please describe) q Yes q No
Current Legal Issues? (Please describe)
q Yes q No
Current /Pending Compensation/Insurance Claims? q Yes
q No
Specify:
Current Treating Psychiatrist and Phone #
Other Professional or Community Service Involvement
Duration of Mental Illness
q less than 1 yr
q 1-5 yrs q more than 5 yrs.
Past Psychiatric Treatment/ Hospitalizations
(include name of hospital and any past reports)
Family History of Psychiatric Illness
History of Medical Illness
Additional Information/Comments
Date:Completed by (Print name): Signature and Designation:
February 10, 2014
3/3
Central Intake Referral Form
Schedule A
The ROHCG respects the privacy laws in Ontario which require us to protect your privacy by protecting your
personal information. We will ensure the confidentiality of any information you give or that is gathered about
you during the course of your stay at the ROHCG. The ROHCG requires your consent to obtain past records
from hospitals and/or mental health agencies in order to provide you with the highest quality of care.
I, _____________________________________, confirm that I understand my rights pertaining to the above.
Consequently, I understand that I have the right to either accept or decline the disclosure listed below.
PLEASE CHECK ONE BOX
Disclosure of past reports from hospitals
and/or mental health agencies
q Yes
q No
I am signing my name below to confirm that I have read the above or it has been read to me, and
I have had a chance to discuss it with a staff member.
Name: Signature: Date:
Staff Witness:
Name:
Signature: Date: