Referral Form for Admission to Homewood Health Centre Patient Information Patient Name: Address: City: Province/State: Postal/Zip Code: Country: Email Address: Telephone: Business/Mobile Phone: Date of Birth (YYYY-MM-DD): Gender: Health Card Number: Version Code: Expiry Date: Department of National Defense Blue Cross Service # (if applicable): Veterans Affairs Canada K # (if applicable): Referring Clinician Information Your Name: Your Health Care Discipline e.g. Family Medicine, Social Worker: ________________________________________ Address: City: Province/State: Postal/Zip Code: Country: Email Address: Telephone: Fax: OHIP Billing # (if referred by an Ontario Physician or Nurse Practitioner): Are you referring as part of: WSIB DND VA Other Agency: No Yes Will you provide this patient care after discharge? If not, who will: __________________________ In order to arrange a timely admission to the most appropriate program, please provide us with clinical information, dating back at least 2 years. Copies of past consults, test results and discharge summaries are very helpful. Primary Reason for Referral: BC Referrers Only: Please indicate if referring to Whole Recovery Assistance Program (WRAP) AMS ☐ Please check all the problems your patient has and star your primary concern: In the Prior to 6 In the Prior to 6 last 6 months last 6 months months ago months ago Eating Disorder Suicide Attempts Substance Abuse Schizophrenia (drug and/or alcohol) Addiction Bipolar Disorder (drug and/or alcohol) Chronic Pain Major Depression History of Abuse or Trauma Hypomania PTSD Mania (post-traumatic stress disorder) Self-Harm Violence (e.g. cutting, burning self) Personality Disorder Aggression Dementia ADHD Social Phobia Flashbacks Panic Disorder Nightmares OCD Dissociation (Obsessive Compulsive Disorder)
Referral Form for Admission to Homewood Health Centre Patient Information Patient Name: Address: City: Province/State: Postal/Zip Code: Country: Email Address: Telephone: Business/Mobile Phone: Date of Birth (YYYY-MM-DD): Gender: Health Card Number: Version Code: Expiry Date: Department of National Defense Blue Cross Service # (if applicable): Veterans Affairs Canada K # (if applicable): Referring Clinician Information Your Name: Your Health Care Discipline e.g. Family Medicine, Social Worker: ________________________________________ Address: City: Province/State: Postal/Zip Code: Country: Email Address: Telephone: Fax: OHIP Billing # (if referred by an Ontario Physician or Nurse Practitioner): Are you referring as part of: WSIB DND VA Other Agency: No Yes Will you provide this patient care after discharge? If not, who will: __________________________ In order to arrange a timely admission to the most appropriate program, please provide us with clinical information, dating back at least 2 years. Copies of past consults, test results and discharge summaries are very helpful. Primary Reason for Referral: BC Referrers Only: Please indicate if referring to Whole Recovery Assistance Program (WRAP) AMS ☐ Please check all the problems your patient has and star your primary concern: In the last 6 months Prior to 6 months ago In the last 6 months Prior to 6 months ago Eating Disorder Suicide Attempts Substance Abuse (drug and/or alcohol) Schizophrenia Addiction (drug and/or alcohol) Bipolar Disorder Chronic Pain Major Depression History of Abuse or Trauma Hypomania PTSD (post-traumatic stress disorder) Mania Self-Harm (e.g. cutting, burning self) Violence Personality Disorder Aggression Dementia ADHD Social Phobia Flashbacks Panic Disorder Nightmares OCD (Obsessive Compulsive Disorder) Dissociation
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