Independent Living Support Program

Referral Form

Date of Referral:

mm/dd/yyyy

It is recommended that the referral source and applicant complete this form together.

Applicant Information:

First Name: / Middle Name: / Last Name:
Address: / City, Province: / Postal Code:
Date of Birth:
Month Day Year / Phone Number:
( ) / May we leave a message?
Yes No
Email: / Personal Health Number: / Gender:
Marital Status: / Cultural Background: / Primary Language:
Source of Income (i.e.AISH, CPP): / Annual Income:

Reason for Referral:

Referral Source:

Referring Agency: / Contact Name:
Frequency of contact (past 12 months): / Relationship to applicant:
Address: / Phone: ( )
Fax: ( )

Family Support/Emergency Contact:

Name:

Relationship to applicant:

Phone No: ( )

Address:

Professional Supports:

Professional support: / Phone: / Address: / Will remain involved in care
Psychiatrist: / ( ) / Yes No
Physician: / ( ) / Yes No
Clinical Support/Case Manager: / ( ) / Yes No
Financial Support Worker: / ( ) / Yes No
Other (Guardian, Trustee, Outreach): / ( ) / Yes No
Other: / ( ) / Yes No

Psychiatric and Physical Health Concerns:

Psychiatric Diagnosis:

Physical Health Diagnosis:

Number of hospitalizations in the past two years due to mental health:

Date of most recent mental health hospitalization:

Reason for most recent mental health hospitalization:

Medication:

Psychiatric: / Other:

Comments:

Known Allergies (medications, food, environmental):

Substance Use/Addictions:

Current Past
Current Past
Current Past
Current Past
Tobacco Use: Yes No
Amount: / Current Past

Addiction Treatment History:

Please check any of the following that are relevant to applicant:

Risk factors: Special considerations:

Suicidal ideation Communication concerns

Suicidal attempts Cultural considerations

Self harm Legal Involvement

Aggression/violence Mobility issues

Anger management

Allergies (life threatening)

Other ______

If yes to any of the above please provide details:

Identified Needs:

Please check the area(s) in which the applicant requires support/services to maximize or maintain independence

ÿ Home management ÿ Mental Health Management

ÿ Financial/Income ÿ Physical Health Management

ÿ Social Supports ÿ Leisure recreation

ÿ Cooking and Nutrition ÿ Vocational/Employment/Volunteering

ÿ Educational ÿ Personal Safety

ÿ Personal Hygiene ÿ Transportation Training and Access

ÿ Coping Skills ÿ Housing

ÿ Daily Routines and Activities ÿ Other

Please add any additional comments or suggestions that will facilitate service planning for the applicant:

Current Housing Situation:

Approved home Private house/Apartment market rent

Family Home Subsidized Housing

Homeless - Couch surfing Supported Housing

Homeless - Shelter Transitional Housing

Homeless - Street Unknown

Hospital Other

Long term Care facility

Living Situation:

Independent

Roommate

Family

Assisted

Please attach a copy of the following with this Referral Form:

  Psychiatric Assessment

  Current Medication Administration Record

  Current Functional Assessment

  Any other information you feel is relevant.

  I have attached a valid Release of Information

I verify that the above information is complete and accurate to the best of my knowledge:

Signature of Applicant: Date:

mm/dd/yyyy

Signature of Referral Source: Date:

mm/dd/yyyy

Please return completed application to:

Independent Living Support Program Manager

Canadian Mental Health Association – Calgary Region

Suite 400, 105 12th Avenue SE

Calgary, AB T2G 1A1

Phone: (403) 297-1700

Fax: (403) 270-3066

1

In accordance with the Health Information Act, the Mental Health Act, the Freedom of Information and Protection of Privacy

Act of Alberta, and the Personal Information and Protection Act, applicants will be informed that all personal information collected will be used for the purpose of assessment, program evaluation and safety. Applicants who wish to appeal a decision related to services can direct their inquiries to the Director of Outreach Services.

Revised October 2016