Acceptance Criteria Hospitalizations: No Major Psych. Symptoms considered intractable Yes # of admissions to Schedule 1 Psych. Units No Criminal Justice Involvement Yes # of admissions to Hospital No Co-existing substance use disorder Yes # of days in hospital in last 12 mths 24 mths No Homelessness or risk of homelessness Yes # of ER visits in the last 12 mths 24 mths No Assessed as able to live more independently Yes Last Discharge: Location: Substitute Decision No Unable to attend traditional Outpatient Services Yes Maker Yes No Contact Information: Waterloo Region is the county of origin or residence No Yes Financial Incapacity Contact Information: Yes No No Community Treatment Order Yes Renewal Date: ADDITIONAL INFORMATION TO AID COMMUNITY INTAKE GROUP History of Psychiatric Involvement: History of Previous Agency Involvement: Present Agency Involvement (amount of time spent, support need, barriers preventing recovery plan from working): Medication Management/Compliance: – Family/Caregiver Stress: Psychosocial Area (interpersonal conflicts; family contact, bio-cultural): Criminal History: Health & Safety Issues (violence to self or others, sexually inappropriate behaviour, housing, dogs, communicable diseases): Effect of Comorbid Conditions: List of Current Strengths/Resources (check all that apply): Economic Resources Education/Skill Resource
Acceptance Criteria Hospitalizations: # of admissions to Schedule 1 Psych. Units # of admissions to Hospital # of days in hospital in last 12 mths 24 mths # of ER visits in the last 12 mths 24 mths Last Discharge: Location: Substitute Decision Maker Yes No Contact Information: Financial Incapacity Yes No Contact Information: Major Psych. Symptoms considered intractable Yes No Criminal Justice Involvement Yes No Co-existing substance use disorder Yes No Homelessness or risk of homelessness Yes No Assessed as able to live more independently Yes No Unable to attend traditional Outpatient Services Yes No Waterloo Region is the county of origin or residence Yes No Community Treatment Order Yes No Renewal Date: ADDITIONAL INFORMATION TO AID COMMUNITY INTAKE GROUP History of Psychiatric Involvement: History of Previous Agency Involvement: Present Agency Involvement (amount of time spent, support need, barriers preventing recovery plan from working): Medication – Management/Compliance: Family/Caregiver Stress: Psychosocial Area (interpersonal conflicts; family contact, bio-cultural): Criminal History: Health & Safety Issues (violence to self or others, sexually inappropriate behaviour, housing, dogs, communicable diseases): Effect of Comorbid Conditions: List of Current Strengths/Resources (check all that apply): Economic Resources Education/Skill Resource
ACTT-referral-screening-Waterloo-region-v.-180713.docx