· REFERRAL FORM Please note: This service is not a crisis service
NAME: / UID/CB#ADDRESS: / DATE OF REFERRAL:
CITY: POSTAL CODE:
/ REFERRAL SOURCE:
PHONE NUMBER: MARTIAL STATUS: / REFERRAL SOURCE PHONE #:
D.O.B. AGE: H.C.# / FAMILY PHYSICIAN:
CLIENT LIVING WITH: TYPE OF HOUSING:
ADM. DATE TO FACILITY: / PHYSICIAN PHONE #:
PHYSICIAN FAX #:
CAREGIVER/NEXT OF KIN: RELATIONSHIP: HOME PHONE #: WORK PHONE #:
CONTACT PERSON RE: APPOINTMENTS, ETC.
1CLIENT 1 CAREGIVER/NEXT OF KIN/SDM / CLIENT/SDM consents to REFERRAL: 1 YES 1 NO
PREFERRED LANGUAGE:
OTHER AGENCIES/SUPPORTS INVOLVED: (List contact & duration of involvement if available)
1 Community Living Agency 1 CCAC 1 Day Program 1 Behavior Therapy Service 1 Family Home Provider
1 Twin Lakes Clinical Services 1 Psychiatrist 1 Boarding Home 1 APSW 1 Other: (Specify)
reason for referral / psychiatric issue/behaviour: / FOR PHYSICIANS:
Please fill in all of the form or it may delay the referral process.
medications/dosages:
allergies/drug reactions:
medical / psychiatric history: (please forward any consultations)
**PLEASE FORWARD MOST RECENT BLOODWORK AND ANY INVESTIGATIONS (I.E. CT SCAN, EKG, EEG,), WHICH HAVE BEEN COMPLETED. IF BLOODWORK/URINALYSIS HAVE NOT BEEN COMPLETED WITHIN THE PAST MONTH, WE WOULD RECOMMEND THE FOLLOWING:
o CBC WITH DIFF (WBC) / o ELECTROLYTES / o LIVER FUNCTION: (AST, ALT, GGT, ALP) / o RBC-FOLATE
o CREATININE/BUN / o TSH / o Cholesterol Profile / o URINE, R&M AND C&S
o Medication Blood Levels / o B12 / o GLUCOSE / o Prolactin
x
FAMILY PHYSICIAN SIGNATURE: OHIP BILLING NUMBER: DATE:
x
REFERRING PHYSICIAN SIGNATURE: OHIP BILLING NUMBER: DATE:
St Joseph’s Hospital Developmental Dual Diagnosis Outpatient Team
100 West 5th Street, Hamilton, Ontario L8N3K7
Tel: 905-522-1155 ext 36768 Fax: 905-381-5619
Dear Family Doctor :
Your patient has been referred to our program by either by your office, the family, or community agency.
Please remember our service is NOT a crisis service, nor do we have a unit with inpatient beds. The following is what we provide and what we need to continue with the referral process:
What do we provide for individuals who are referred to our service?
We provide treatment and short term follow-up by team members to ensure a personalized safe plan of care is developed for individual’s referred to our team.
We provide: medication reviews for clients for whom a medication change may be in order with follow-up to those changes.
We do NOT have a unit dedicated to those individuals with Intellectual Disabilities. Admission if needed will be to an active treatment bed on the admission unit of the hospital where our clients are integrated with other clients. Planned admission is negotiated through the Bed Utilization Manager
We provide: education to agencies, interest groups, caregivers and families in the area of
· Medication administration
· Syndrome and illness education
· Special issues for individuals with a dual diagnosis.
We provide: psychiatric assessment by a multidisciplinary team made up of psychiatrists, nurses, and other’s to whom we refer.
We refer to other outpatient professionals or organizations in the area of mental health for individuals with Intellectual Disability such as Developmental Services Ontario and Hamilton Brant Behavior Services.
What is the referral process I can expect to see?
After the information requested is received, an appointment is then made for team members to do a visit in the home of the client in order to collect more information and see the client in their own living environment.
The data that is collected is compiled into a document for the team to use in their assessments. This is reviewed before the client comes to the hospital to see the doctors and nurses.
During the meeting with the doctor, a treatment plan is decided upon by the team in collaboration with the caregivers, client and family. This could mean a new medication, new programs, or an increase in the dose of a medication the client already takes, or anything else that might seem the best route to take in the client’s best interest.
The team will follow the progress of the treatment plan and report back to the doctor on how the individual is progressing.
When the client is stable and improvement is seen and felt, letters will be sent to the General Practitioner for continued follow up, outlining the progress and condition of the client.
S/he client is then referred back to the Family Doctor for follow up monitoring.
We remain available should the need arise in the future.
What information do you as GP need to provide for our referral to continue:
· The current health insurance number (OHIP)
· The family doctor’s name, address and telephone number and fax number.
· A updated list of the current medication and pharmacy involved in the care.
· Copies of past consultation notes you as GP will have including: other places the client has been to for assessment, any consultation notes you may have
· Please order and copy us results, blood work including: fasting glucose;
· Past developmental history and current problems.
Including
Thank you for your referral to our team. Again, once we received the information requested, we will start the referral process. We will be sending you notes as we go on with the assessment to keep you informed of how our process has gone and what we have ordered.