DOOR IS THE RIGHT DOOR” “EVERY Adult Mental Health Program The Religious Hospitallers Of 613 544-3400 x 2551 Of the Hotel Dieu of Fax: 613-548-6095 Client Information Referral Agent Information Name: Date of Referral: Address: Agency/Source: Date of Birth (dd/mm/yr)__/__/__ Telephone (home): Telephone: Telephone (work): Fax: Alternate contact person (name): Health Card #: Version code: Family Physician/Psychiatrist (if different from above) May we contact the client directly? Yes No Can a detailed message be left? Yes No Telephone (direct): Any Communication barrier? Yes No Please specify: Reason for Referral: CURRENT SITUATION PSYCHIATRIC HISTORY Current working psychiatric diagnosis Previous diagnoses None Current mental health/psychiatric contacts None Previous out-patient mental health None /community supports (please describe) and /or addiction treatment (please describe) Current medical conditions Previous in-patient psychiatric admissions (please describe) None Yes No (please describe) Current medications (please describe) None Signature: Date: (of Referral Source) Note: 1) Signature acknowledges that this referral will be assessed by one of the Access Coordinators. here to indicate that we can contact the most appropriate service for your client, and redirect the referral. 2) Please append/forward any relevant consultation reports/discharge summaries.
“EVERY DOOR IS THE RIGHT DOOR” The Religious Hospitallers Of Of the Hotel Dieu of Adult Mental Health Program 613 544-3400 x 2551 Fax: 613-548-6095 Client Information Referral Agent Information Name: Address: Date of Birth (dd/mm/yr)__/__/__ Telephone (home): Telephone (work): Alternate contact person (name): Health Card #: Version code: May we contact the client directly? Yes No Can a detailed message be left? Yes No Any Communication barrier? Yes No Please specify: Date of Referral: Agency/Source: Telephone: Fax: Family Physician/Psychiatrist (if different from above) Telephone (direct): Reason for Referral: CURRENT SITUATION PSYCHIATRIC HISTORY Current working psychiatric diagnosis Previous diagnoses None Current mental health/psychiatric contacts None /community supports (please describe) Previous out-patient mental health None and /or addiction treatment (please describe) Current medical conditions (please describe) None Current medications (please describe) None Previous in-patient psychiatric admissions Yes No (please describe) Signature: Date: (of Referral Source) Note: 1) Signature acknowledges that this referral will be assessed by one of the Access Coordinators. here to indicate that we can contact the most appropriate service for your client, and redirect the referral. 2) Please append/forward any relevant consultation reports/discharge summaries.
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