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.)

_______________________________________________________________________________ __________________________________________________________________________________

Concurrent Issues:

_______ 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:

CLIENT CONSENT TO DISCLOSURE

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: __________________________________________________________________________



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