Fei Yue Community Services Referral Form For COMIT

Please email to Tel: 6661 9488 Fax: 6661 9480

SECTION 1: REFERRAL DETAILS
Agency Name: / Date of Referral:
Name of Referring Staff: / Designation:
Tel No: / Email:

Has the client / *family member consented to this applicationand agreed to the disclosure of enclosed information to relevant agencies/service providers to facilitate the application Yes No

(*If client lacks the mental capacity to give consent, the client’s family member can give consent on his/her behalf)

SECTION 2: CRITERIA FOR REFERRAL
COMIT
The COMmunity Intervention Team (COMIT) is embedded in the community to provide holistic services for clients with mental health needs and their caregivers so that they can live and age well at home and in the community. It is an allied health-led team which provides psycho-social therapeutic intervention for clients with mental health needs and supports their caregivers in coping with caregiving for the loved ones.
Reasons for Referral
(Support required for client) / Counselling Caregiver Support Support Group
Community Re-Integration Medication Management
Mental Health Assessment Psycho-education
Other Reason(s) please specify
______
  1. Client’s Mental Health Information. If client is suspected or diagnosed with mental illness, please indicate the diagnosis from the list of mental health conditions as follows (may tick more than one):
Anxiety Bipolar Disorder
Suspected AnxietyDementia / Cognitive Impairment
SchizophreniaOCD (Obsessive Compulsive Disorder)
Suspected Schizophrenia / PsychosisOthers:______
Depression
Suspected Depression
Other types of Mood Disorder (e.g. adjustment, stress, anger, etc)
Currently followed up at (institution name): ______
Onset of illness (duration): ______
On medication: Yes No
2. Singaporean and Permanent Residents
3. Address of residency falls within service boundary (Serangoon/ Hougang/ Choa Chu Kang/ Bukit Panjang/
Bukit Batok/ Woodlands/ Taman Jurong.)
SECTION 3: PERSONAL PARTICULARS OF CLIENT
Name: / NRIC:
Gender: / Male
Female / Date of Birth: / / / (dd/mm/yy) / Age:
Address:
(Residential) / Postal Code:
(Residential)
Contact No: / (Home) / (Mobile) / (Office)
Race: / Chinese Malay Indian Eurasian Others / Citizenship: Singaporean / Pink
Singapore PR / Blue
Marital Status: / Single Married Widowed Unknown
Separated Divorced Cohabited
Language Spoken /& Dialect(s):
English Mandarin Malay Tamil
Cantonese Hakka Hokkien Hainanese Teochew Others:
Next of Kin:
Name: ______Relationship: ______Contact No.: ______
SECTION 4: OTHERRELEVANT INFORMATION
  1. Other Medical Condition
  1. Physical Illness ; No Yes , please specify : ______.
  1. Type of Illness:
Chronic (persistent or long lasting in its effect)
Acute (starts suddenly but is short-lived)
Unknown/Not indicated
  1. Within the last 3 months, has there been any incidence of the following:
Suicide Attempt Self Harm Violent Behavior Sexual Offence
Extreme Impulsivity Others; please specify
  1. Please enclose a copy of the latest discharge / medical summary if available.
  1. Any other relevant information? ______

CMH_COMIT@FeiYue Referral Form

Updated on:10th Jan 2018