Download Client`s Name: DOB (yy/mm/dd)

Developmental Disabilities Service
Physician/Primary Health Care Provider (PHCP) Referral Form
❑ Referral
❑ Re-Referral (Please complete Section A and B only and attach note including any new pertinent information)
Please include any clinical information you may have. Incomplete forms will NOT delay the referral process.
A.
PHCP Name: ________________________________________ PHCP Phone #: (___)_________________
Mailing address: ____________________________________________ Fax #: (___)__________________
B.
Patient’s Name: __________________________________ DOB_____________ ❑ Male ❑ Female
(Last/First)
(y/m/d)
Address: ______________________________________________________________________________
(street)
(city)
(postal code)
Phone #.: (_____)__________________________
Health Card #:___________________________
Emergency Contact Name/relationship: __________________________ Phone#: (___)_________________
Is patient aware of referral? ❑ Yes ❑ No
Has a formal assessment and declaration of permanent incapacity, a process during which a POA (or PGT)
becomes the official SDM, been completed? ❑ Yes ❑ No ❑ Unknown
Is the patient capable to consent to treatment? ❑ Yes ❑ No ❑ Unknown
If No, Substitute Decision Maker is: ____________________________ SDM Phone #:(___)_____________
Chief Complaint/Reason for Psychiatric Assessment: ____________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
When did symptoms begin? ________________________________________________________________
Describe symptoms when unwell?___________________________________________________________
______________________________________________________________________________________
Any aggravating factors? __________________________________________________________________
______________________________________________________________________________________
Alleviating factors? _______________________________________________________________________
Psychiatric History
Current psychiatric involvement? ❑ Yes ❑ No Psychiatrist’s Name: _____________________________
Current psychiatric diagnosis: ______________________________________________________________
Date
Past Diagnosed Mental Illness(es)
Doctor
Degree of Developmental Disability: ❑ Mild ❑ Moderate ❑ Severe ❑ Profound
Has a psychometric assessment been completed? (IQ testing) ❑ Yes ❑ No *If Yes, please include report if able
1. Is patient able to describe symptoms?
2. Does patient have understanding of diagnosis?
3. Does patient understand his/her intervention(s)?
❑ Yes ❑ No ❑ Some
❑ Yes ❑ No ❑ Some
❑ Yes ❑ No ❑ Some
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How does patient describe any of above 3 questions? ___________________________________________
______________________________________________________________________________________
Has patient visited the ER in the past year? ❑ Yes ❑ No If yes, please list __________________________
______________________________________________________________________________________
Past Psychiatric Hospitalizations (attach sheet if needed)
Facility
Admission
Date
Discharge
Date
Reason
Diagnosis
Past Medical/Surgical Hospitalizations (including pregnancies)
Facility
Admission
Date
Discharge
Date
Reason
Diagnosis
Health History (*Attach most recent labwork, include abnormal blood work, and any imaging reports
to speed up the processing of this referral)
Any history of:
Yes No
If yes, date & description
Seizure Disorder
❑
❑______________________________________________
Dementia (Alzheimer’s, Lewy body, Frontal lobe) ❑
❑______________________________________________
Neurological Problems (Tourette’s, head injury)
❑
❑______________________________________________
Cardiovascular Conditions
❑
❑______________________________________________
Respiratory Conditions (sleep apnea, asthma)
❑
❑______________________________________________
GI Complications (GERD, H Pylori)
❑
❑______________________________________________
Genitourinary Conditions
❑
❑______________________________________________
Skin Conditions
❑
❑______________________________________________
Musculoskeletal Conditions (Scoliosis)
❑
❑______________________________________________
Endocrine (Thyroid, Diabetes, Cirrhosis)
❑
❑______________________________________________
Hypertension
❑
❑______________________________________________
Impaired Vision
❑
❑______________________________________________
Impaired Hearing
❑
❑______________________________________________
Dental Problems
❑
❑______________________________________________
Genetic Conditions
❑
❑______________________________________________
Past Reportable Diseases (Hep, HIV)
❑
❑______________________________________________
Risks (self abuse, suicide attempt, legal, homeless) ❑
❑______________________________________________
Drug Use (alcohol, tobacco, cannabis, caffeine)
❑
❑______________________________________________
Cancer
❑
❑______________________________________________
Sleep Problems (insomnia)
❑
❑______________________________________________
High Cholesterol
❑
❑______________________________________________
Pregnancy
❑
❑______________________________________________
Other (please describe) _____________________ ❑
❑______________________________________________
Medication Contraindications: ______________________________________________________________
Height: _______Weight (+ date taken):_____________BP________ Allergies: ________________________
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Past Psychotropic Medications:
Drug Name
Dose/
Time(s)
Taken
Date
Started
Date
Discontinued
Reason for
Discontinuation
Was it Beneficial?
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
Current Medications:
*Attach extra sheet if necessary
Including any prn/over-the counter/herbal/supplements the patient takes. *Provide a print out from the
pharmacy if easier/able.
Drug Name
Dose/ time(s)
Taken
Date
Started
Is it Beneficial?
List any side effects noted by
patient/ care provider
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
Pharmacy: ________________________________________ Phone No:____________________________
** Primary Care of Adults with Developmental Disabilities Canadian Consensus Guidelines are available for
reference @ http://www.cfp.ca/content/57/5/541.full
Completed by (if other than family physician):_____________________ Date Completed: ________________
Please Fax/Send to:
Amy Betzner-Massana
Developmental Disabilities Service
In partnership with
CMHA Nipissing
156 McIntyre St. W.
North Bay, ON P1B 2Y6
705-474-1299, #224
705-474-5325 (Fax)
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Please have your service provider/care provider complete the following intake package
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Developmental Disabilities Service – Intake Package
❑ Referral ❑ Re-referral
❑ Please indicate if assistance is requested to complete paperwork
Client’s Name: ___________________________ D.O.B. (yy/mm/dd): _________________________
Address:
________________________________________________________________________
(Street/Box No., if appl./City/Postal Code)
Telephone No.: _(___)__________________________ Health Card# ___________________________
Family Doctor/Primary Care Provider: ___________________________________________
Tel. No.:__(___)__________________________
Fax No.: __(___)____________________________
Mailing Address: _____________________________________________________________________
(Street/P.O. Box/City/Postal Code)
Referred by: ______________________________________________________________________
(Name/Agency)
Tel. No.:__(___)__________________________
Address:
Fax No.: __(___)____________________________
_______________________________________________________________________
(Street/City/Postal Code)
1. Is the client aware of the referral? ❑ Yes
❑ No
2. Is client able to make their own treatment decisions for themselves? ❑ Yes ❑ No
a) If not, who makes the treatment decisions for the client? _______________________________________
b) If so, has this person been legally appointed as the Substitute Decision Maker (SDM)? ❑ Yes ❑ No
Contact: _______________________________________________________________________________
* See education form enclosed. If you have any questions regarding this section, further discussion is
available upon intake interview with clinician.
3. Has client had eligibility confirmed for MCSS services at the DSO? ❑ Yes ❑ No
4. Has an application package been completed at the Developmental Services Ontario (DSO)?
❑ Yes ❑ No If yes, please enclose copy of Assessor Summary Report from DSO.
5. Has a Functional Behavioural Assessment (FBA) been completed? ❑ Yes ❑ No
If Yes, date: ___________(yy/mm/dd) *Please attach copy or list name of Assessor/Agency:
________________________________________________ Phone #:_(___)______________
6. Has an Ontario Common Assessment of Need (OCAN)-self assessment been completed? ❑ Yes ❑ No
-staff assessment been completed? ❑ Yes ❑ No
If Yes, date____________ (yy/mm/dd) Contact person: __________________ Phone #:(___)___________
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Client Identification:
*Please select one from each category below.
Gender:
❑ Male ❑ Female ❑ Other ❑ Declined to answer ❑ Unknown
Preferred Language:
❑ English ❑ French ❑ Other: _______________________________
Income Source:
❑ ODSP ❑ Employment ❑ Family ❑ Other ❑ Declined to answer ❑ Unknown
Aboriginal Origin:
❑ Aboriginal ❑ Non-Aboriginal ❑ Declined to answer ❑ Unknown
Marital Status:
❑ Single ❑ Married/common law ❑ Partner/significant other ❑ Divorced ❑ Widowed ❑ Separated
❑ Declined to answer ❑ Unknown
Citizenship Status:
❑ Canadian ❑ Permanent Resident ❑ Temporary Resident ❑ Refugee ❑ Declined to answer ❑ Unknown
Living Arrangements
A. Does client live with anyone?:
❑ Self ❑ Spouse/partner ❑ Spouse/ partner & others ❑ Children ❑ Parents ❑ Non-relatives ❑ Relatives
❑ With Others (complete Part B)
Living Arrangements continued:
B. If you indicated lives “with Others” please identify corresponding category:
❑ Approved homes & Homes for Special care ❑ Correctional/probation facility ❑ Domiciliary hostel
❑ General hospital ❑ Psychiatric hospital ❑ Other specialty hospital ❑ Long term care facility/nursing home,
❑ No fixed address ❑ Hostels/shelter ❑ Private house/apartment – owned/market rent
❑ Municipal non-profit housing ❑ Private non-profit housing ❑ Private house/apartment – other/subsidized
❑ Retirement home/seniors residence ❑ Boarding house ❑ Supportive housing –congregate living
❑ Supportive housing- assisted living ❑ Unknown ❑ Client declined to answer ❑ Other _______________
Waitlists:
1. a. Is client on waitlist for higher/alternate level of care? ❑ Yes ❑ No If Yes, how long? _____________
b. If Yes, why?:________________________________________________________________________
2. During this time, were there any experiences with: ❑ ER visits ❑ Legal difficulties
❑ Out of region placements ❑ Hospitalizations ❑ Use of specialized accommodations
Employment Status:
❑ Independent ❑ Assisted/supportive ❑ Sheltered Workshop ❑ Non-Paid work ❑ Casual sporadic
❑ Alternative businesses ❑ No Employment- other activity ❑ Declined to answer
❑ No Employment of any kind ❑ Unknown
Reason for Psychiatric Referral/Presenting Issues: __________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
A. Possible Issues:
❑ Activities of daily living ❑ Attempted suicide ❑ Educational ❑ Financial ❑ Housing
❑ Substance Abuse issues ❑ Physical Abuse ❑ Legal ❑ Sexual Abuse ❑ Problems with Addictions
❑Threat to Others ❑ Threat to Self ❑ Symptoms of Serious Mental Illness ❑ Problems with Relationships
❑ Occupational/Employment/Vocational ❑ Other_____________________
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B.
❑ Medication review ❑ Diagnosed with an Autism Spectrum Disorder
❑ Significant Life Events (select all that apply):
❑ Change in primary staff ❑ Recent completion of school
❑ Change in roommate
❑ Move of residence/home ❑ Lost job/ financial crisis
❑ Relationship issues
❑ Serious illness/loss
❑ Legal issues
❑ Other ____________________
C. Symptom Checklist:
*Indicate when did symptoms begin? ________________________________
❑ Agitation ❑ Social withdrawal ❑ Lack of spontaneity ❑ Apathy ❑ Grandiosity ❑ Physical symptoms
❑ Delusions ❑ Hallucinations ❑ Poor communication skills ❑ Difficulty in abstract thinking ❑ Hostility
❑ Stereotype thinking ❑ Emotional unresponsiveness ❑ Lack of drive or initiative ❑ Suspiciousness
Current Diagnosis ______________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Psychiatric History:
1. Has client been hospitalized due to mental health issues during the past two years?
❑ Yes ❑ No ❑ Declined to answer ❑ Unknown *If Yes, Total # of admissions: ___________________
2. How many times has the client visited an Emergency Department over the past 6 months for mental
health reasons? ❑ None ❑ 1 ❑ 2-5 ❑ 6 or more ❑ Declined to answer ❑ Unknown
3. Have there been other hospitalizations (for possible medical reasons)? ❑ Yes ❑ No
If Yes, briefly state reason & year__________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Family History:
*indicate relationship to client and diagnosis
Do you know of any biological relatives who have a history of:
❑ Mental illness _________________________________________________________________________
❑ Major medical illness ___________________________________________________________________
❑ Genetic / neurological diorder_____________________________________________________________
❑ Severe substance abuse ________________________________________________________________
❑ Suicide attempts_______________________________________________________________________
❑ Psychiatric hospitalizations ______________________________________________________________
❑ Developmental Disability ________________________________________________________________
LEGAL HISTORY:
A) Does client currently have any legal issues? (select one):
❑ Civil ❑ Criminal ❑ None ❑ Declined to answer ❑ Unknown
B) Current legal status (check all that apply):
Pre-Charge
❑ Pre-charge diversion
❑ Court diversion program
Outcomes
❑ Charges withdrawn
❑ Stay of proceedings
❑ Awaiting sentence
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Pre-Trial
❑ Awaiting fitness assessment
❑ Awaiting trail (with or without bail)
❑ Awaiting criminal responsibility assessment (NCR)
❑ In community on own recognizance
❑ Unfit to stand trial
Outcomes continued
❑ NCR (Not criminally responsible)
❑ Conditional discharge
❑ Conditional sentence
❑ Restraining order
❑ Peace bond
❑ Suspended sentence
Custody Status
❑ ORB detained –community access
❑ ORB conditional discharge
❑ On parole
❑ On probation
Other
❑ No Legal problem (includes absolute discharge
& time served- end of custody)
❑ Declined to answer
❑ Unknown
Background:
Where was client born and raised? ________________________________________________________
Pregnancy:
Duration (in months): ______ Any complications? ❑ Yes ❑ No *If Yes, please describe:_______________
______________________________________________________________________________________
Delivery:
❑ Spontaneous ❑ Induced ❑ Caesarean Birth Weight: ________ lbs ________ oz
Were there any complications? ❑ Yes ❑ No If yes, please describe: _____________________________
______________________________________________________________________________________
Milestones:
Please indicate at what age (approximately) each of these milestones was reached:
Sat up:_______ Walked: _________ Talked: _________ Toilet Trained: ________ Puberty: __________
Please describe client’s childhood temperament/behaviour: _______________________________________
______________________________________________________________________________________
Educational History: (select one)
A.
❑ No formal schooling
❑ Some Elementary/junior high
❑ Some secondary/High
❑ Secondary/High
❑ Some College /University
❑ College or University
❑ Declined to answer
❑ Unknown
B.
❑ Currently attending school
Childhood Illnesses: (e.g. Meningitis, Measles, Mumps) ❑Yes ❑ No *If yes, please indicate illness and
approximate age it occurred: _______________________________________________________________
OTHER:
1. a. Does the client have any children? ❑ Yes ❑ No
b. If yes, please provide list (include present age) and describe relationship: _______________________
______________________________________________________________________________________
2. a. Father’s Name: ______________________ ❑ Current ❑ Past ❑ No involvement with the client
b. Mother’s Name: ______________________❑ Current ❑ Past ❑ No involvement with the client
c. Number of Siblings: __________________
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3. Describe client’s relationship with family members: ____________________________________________
______________________________________________________________________________________
4. Briefly describe relationships with significant others, including friends, siblings and other primary
support providers: _____________________________________________________________________
5. Describe hobbies/interests: ______________________________________________________________
6. Describe likes/dislikes: __________________________________________________________________
7. Describe spiritual needs: ________________________________________________________________
8. Describe client when well: _______________________________________________________________
9. Describe goals/ hopes for the future: _______________________________________________________
10. What are the perceived needs in order to get there? __________________________________________
11. How does the client view his/her mental health? _____________________________________________
12. Is culture (heritage) an important part of the client’s life? ______________________________________
Current Medications: Including any prn/over-the counter/herbal/ supplements the client takes. (Attach extra
sheet if necessary).
Drug Name
Dose/Time
Date
Is it Beneficial?
List any side effects
Taken
Started
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
Pharmacy:_____________________________________ Phone No: (___)________________________
1. Does the client understand the reason(s) for taking his/her current medication(s)? ❑ Yes ❑ No ❑ Some
2. Are the above medication(s) taken as prescribed? ❑ Yes ❑ No ❑ Some
3. Is assistance needed/provided to take above medication(s)? ❑ Yes ❑ No ❑ Some
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Agency Involvement(s): Please describe any other services/agency currently involved:
Name of Service/Agency
Type of
Length of
Contact Person/Number
Assistance
Involvement
Additional Information: ___________________________________________________________________
______________________________________________________________________________________
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Thank you. Developmental Disabilities Service (DDS)
Amy Betzner-Massana
Developmental Disabilities Service
In partnership with
CMHA Nipissing
156 McIntyre St. W.
North Bay, ON P1B 2Y6
705-474-1299, #224
705-474-5325 (Fax)
OFFICE USE ONLY
Date completed
referral received:
(yy/mm/dd)
Date of first
communication with
referral source:
(yy/mm/dd)
Received by
(clinician):
Date print out of the pharmacy
medication listing received:
(yy/mm/dd)
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