APPLICATION/REFERRAL FORM |
You can apply to any of the
agencies affiliated with this web site (ABEL Enterprises, Adult Mental Health
Services, Canadian Mental Health Association, Erie's North Shore Housing
Incorporated and The Community Support Program) by contacting them directly for
more information, or for your convenience you can print out this referral form,
fill in all the necessary information, and mail it or fax it to the:
ADULT MENTAL HEALTH SERVICES OF HALDIMAND-NORFOLK
216 West Street, Suite 103
SIMCOE, Ontario N3Y 1S8
Fax (519) 426-3257
or
26 Main Street North, Box 760
HAGERSVILLE, Ontario N0A 1H0
Fax (905) 768-5804
For Assistance Phone 1-877-909-4357 (HELP)
All referrals will be held with the strictest of confidence and will be
forwarded to the appropriate service provider to meet your needs.
Haldimand-Norfolk Mental Health Service Providers
REFERRAL FORM
This form is to be used for accessing all mental health services for
adults in Haldimand-Norfolk
Abel Enterprises, Adult Mental Health Services, Canadian Mental Health
Association, Community Support Program, Erie's North Shore Housing, Resource
Centre and True Experience.
Client Name ____________________________________ Date of Birth
__________________ Male/Female
Address________________________________________________________________________________
Home Telephone _____________________________ Work
Telephone____________________________
Health Card Number __________________________________________ Version
Code_________________
Family
Doctor_____________________________Telephone________________Fax___________________
Reason for Referral:
_______________________________________________________________________________ __________________________________________________________________________________
Is the client aware of this referral?
_______Yes _______No
Present Symptoms: (Please check the symptoms that best describe the client's present condition.)
_______ Mood Changes _______ Psychomotor Changes
_______ Anxiety - Panic _______ Obsessions, Compulsions
_______ Angry, Irritable, Agitated _______ Unusual Mannerisms or Behaviour
_______ Feelings of Worthlessness/Hopelessness _______ Uncooperative
_______ Guilt _______ Poor Judgement, Insight
_______ Disorientation _______ Thought Disturbances
_______ Poor Concentration _______ Hallucinations
Weight: _______Gain _______ Loss; _______ Suicidal Thoughts/Intent
Sleep: _______Increase _______ Decrease; _______ Past Suicidal Attempts
Appetite: _______Increase _______ Decrease _______ A Risk to Others?
Energy: _______Increase _______Decrease
Additional Information: (duration, precipitating events, other symptoms of this event or episode)
_______________________________________________________________________________ __________________________________________________________________________________
For which of the following services is the referral made?:
_______ Psychotherapy _______ Housing
_______ Psychiatrist and/or Clinician Assessment _______ Vocational
_______ Medication Issues _______ Life/Skills
_______ Social/Recreational/Peer Support _______ Community Support
_______ Support Group _______ Other
_______ Don't Know
Psychiatric Diagnosis: (if available) _________________________________________________________
Has the client been admitted to hospital for psychiatric problems in the last two years?
_______ Yes _______ No
Hospital______________________________________________
Dates ___________________________________________________
Current Medications: (Please list drug names and dosage) _______________________________________________________________________________ _______________________________________________________________________________
Changes in Functioning: (Please checkmark as appropriate.
Functions |
Mild |
Moderate |
Severe |
Occupation |
' | ' | ' |
Education |
' | ' | ' |
Social/Relational |
' | ' | ' |
Self-Care |
' | ' | ' |
Client Service Preferences, if any: (such as language, location, etc.)
_______________________________________________________________________________ __________________________________________________________________________________
_______ Drug Abuse _______ Alcohol Abuse
_______ Behaviour Problems _______ Legal Problems
_______ Marriage Problems _______ Family Problems
_______ Developmental Delay _______ Significant Medical Problems
_______ Physical Disability _______ Hearing and/or Visually Impaired
_______ Employment Problems _______ Acquired Brain Injury
_______ Housing Issues _______Financial Problems
Additional Information: _______________________________________________________________________________ _______________________________________________________________________________
The client is presently using the following services:
_______ Adult Mental Health Services of Haldimand-Norfolk (AMHS)
_______ Erie's North Shore Housingþ Childrens' Aid Society
_______ Abel Enterprises _______ Community Support Team
_______ True Experience _______ Home Care (CCAC)
_______ CMHA _______ Resource Centre
_______ R.E.A.C.H. _______ Private Psychiatrist
Other ________________________________
_______Hamilton Psychiatric Hospital
_______ St. Thomas/London Psychiatric
_______ Brantford General Hospital Mental Health Services
Other Hospital ______________________________
It is suggested that referral sources obtain the following approval:
I, ____________________________________ hereby consent to the disclosure or transmittal to, or to get information from Adult Mental Health Services of Haldimand-Norfolk (and the Haldimand-Norfolk Resource Centre) or Abel Enterprises or Canadian Mental Health Association or Erie's North Shore Housing Inc. (and the Community Support Program) or True Experience Support Housing & Community Work Program, of this referral information, as required.
Client Signature: ______________________________________ Date:__________________________
Referring Source: (Please
print)__________________________________
Date of Referral:_______________________
Signature: __________________________________________________________________________