Mental Health and Substance Use

Mental Health and Substance Use

Mental Health Tertiary and Licensed Residential Referral Form

Instructions for the Mental Health Tertiary / Licensed Residential Referral Form
In order to match applicants to the most appropriate service and facility, the Community Residential Program (CRP) team and / or the Tertiary Service team requires detailed information about the applicant; therefore, fill out this form as detailed as possible. This will alleviate unnecessary delays.
Attach the following supporting documents to your client’s referral if available,
A completed referral form
Client in agreement with referral
A recent psychiatric assessment / consult
A discharge summary if client was recently hospitalized
Involuntary status - please send forms 4, 5, 6, 15, 20
Last review panel date
A current medication list
A recent Occupational Therapy assessment, if one has been recently been completed
If currently on an inpatient unit, 1 - 2 weeks of nursing / social work / progress notes outlining the client’s current status and admission assessments.
If currently in the community, recent case manager / psychiatrist notes outlining client’s current status
Any relevant medical notes that outline physical health issues, including allergies, recent illness or conditions.
Any laboratory investigations / results
ECT records of current treatment and details of past ECT treatments.
A detailed addictions recovery plan, if applicable
Any past mental health treatment notes
Please note: Mental Health Licensed Residential referrals will only be kept on the referral list for 3 months, with the exceptions of

• Clients on a Fraser Health Inpatient unit
• Clients in a Tertiary Care facility

At the 3 month period, the referral source will be sent a letter informing them that the applicant has been removed from the list and an updated referral must be resubmitted should the client still require a licensed facility. For clients that are referred from an inpatient unit or tertiary care facility, that have been discharged back into the community, their 3 month limit will be from the original date referred.
Service Required(tick one or both):
Community Residential Program / Tertiary Services
Contact Information
Tertiary
Specialized Residential
(Cottonwood and Connelly Lodges)
Community Tertiary Services
(Memorial Cottage and Cypress Lodge)
Intensive Tertiary Rehabilitation
(Cedar Ridge) / Rick Gremm / Resource andSystemsLeader
Phone: (604) 517-8609
Cell: (604) 613-2666
Fax: (604) 519 8548
Email:
Raena Zapp / Referral Coordinator| TertiaryMental Health Services
Phone: (604) 520-0911 loc. 522769
Cell: (604) 506-3245
Fax: (604) 519 8548
Email:
Mental Health Licensed Residential / Tamara Donkersgoed / Referral Coordinator
Phone: (604) 517-8664
Cell: (604) 614-6573
Fax: (604) 519 8548
Email:
A. Demographics
name / DOB / age
address:
street city postal code
current living situtation (homeless, name of facility, eviction notice, etc)
telephone: / phn / GENDER
client aware (yes/no) / client signature
if in hospital, which hospital / date of admission / date made alc
B. Referrer information
name: of person referring / name of referring agency / date of referral
address:
street city postal code
telephone: / fax / email
Mental Health Involvment(If other than the above)
mh team / case manager/ therapist / telephone
psychiatrist / telephone / gp / telephone
other agencies/persons involved in clients care
C.next of kin or contact in case of emergency
name:
address:
street city postal code
telephone: / relationship to person being referred:
D. Diagnosis
axis i
axis ii
axis iii
axis iv
axis v
gaf score:
E. Psychiatric History

1. Please list hospitalizations, treatment centers, mental health centre involvement - include dates and reasons (attach recent psychiatric/medical consults if available)

1. Baseline (What is the clinical picture when the client is functioning well)

1. Signs of Decompensation; Possible Precipitants; History of Rapid Decompensation

Does the client have a relapse plan or WRAP plan?
4. describe known stressful factors:
5. traumatic events in person’s life (please provide details, eg abuse history) Yes No
Abuse: Sexual Physical
Emotional Financial
Neglect
Serious Injury/ Illness
Death of a loved one
Other
F. medication management
current medications: (include alternative / herbal remedies)
medication compliance / concerns:
side effects to medications / observable side effects:
symptom management: (coping skills / activities)
Experience in managing own medications:
G. mental status exam
hallucinations:
delusional thoughts / patterns:
general mood:
motivation / energy:
insight / judgement:
memory / orientation:
suicidal ideation:
H. RISK BEHAVIORS Yes No
Alcohol: / Current Past None / Criminal Behaviour: / Current Past None
Drugs: / Current Past None / Fire Risk: / Current Past None
Violence: / Current Past None / Self-Harm/Suicide History: / Current Past None
Poor Self Care: / Current Past None / Poor Nutrition: / Current Past None
Any History of Sexual Abuse or Involvement of MCFS Regarding Children in Care of Client: Yes No
Is the client at risk for falls Yes No
Please comment if current or past has been checked off (please include dates and details of risk) (please comment on or attach A&D recovery/safety plan if applicable):
I. Use of substances
type / frequency / concerns
history of use / misuse: List hard reduction strategies
J. Psycho / social / cultural / spiritual
Client strengths
Natural Support system
Client’s core values
Educational background
Vocational experience
Social recreational preferences
Cultural / Spiritual considerations(INCLUDE ENGLISH OR OTHER LANGUAGES SPOKEN)
K. physical health status
oral / dental: (name of dentist)
nutritional status / appetite: (food dislikes / preferences)
weight loss / weight gain:
current height
current weight
elimination:
cardiac: (bp, heart conditions)
respiratory (sob, copd, asthma – use of inhalers)
neurological (any history of seizures)
sexual: (hiv, sexually transmitted diseases, birth control)
skin / nails: (skin integrity, rashes / skin conditions)
sensory / hearing: (use of hearing aid)
vision: (contacts, glasses)
mobility: (limitations)
immunizations/screening:
□ tb □ pneumococcal □ flu vaccine□ tetanus
date date date date
hep a: □ #1□ #2hep b: □ #1 □ #2 □ #3□ other
L.capability / leagal status
capability status:
□ capable□ incapable of financial affairs□ incapable of person / committee:
□ public trustee□ same as contact person□ other
voluntary or extended leave:
#1 Date of Original certificates ______
#2 Date of involuntary admision ______
#3 Date of subsequent renewals ______
#4 Date of pending referrals ______
Conditions of extended leave
M. HOUSING HISTORY (please comment)

• Current (length)

• Past year

• Moves/Evictions - Reasons

• Licensed Facility

• Supported Housing

• Previous/Current Subsidies

• Other

N. Financial Information
Source of Income: / Work Family PPMB CPP OAP GIS PWD / Other:
Able to Manage Own Finances: / Person Managing Client’s Finances / Phone
Yes No Net Monthly Income: / $ / If CRP, is client aware of per diem / Yes No
O. Psycho / social / cultural / spiritual
Client strengths
Natural Support system
Client’s core values
Educational background
Vocational experience
Social recreational preferences
Cultural / Spiritual considerations
P. FUNCTIONAL
Manages Personal Care / Yes No / Uses Public Transportation / Yes No
Manages Medications / Yes No / Occupational Therapist Assessment / Yes No
Maintains Meaningful Activities / Yes No / Mobility Issues / Yes No
Has Social Contacts / Yes No / Able to walk without aids / Yes No
Maintains a Healthy Diet / Yes No / Uses Cane / Yes No
Able to Feed Self / Yes No / Uses Walker / Yes No
Manages Housecleaning Tasks / Yes No / Uses Wheelchair / Yes No
Does Own Laundry / Yes No / Able to use stairs / Yes No
Manages Own Finances / Yes No / Other / Yes No
Comments:
Q. SUPPORT REQUIREMENTS SUMMARY
RATINGCODES / PLEASE RATE / Comments
1 = Little/No Support (Monthly or Less) / 3 = 1–3 times/week
2 = Twice Monthly / 4 = Daily Support
1 / Psychiatric Illness Management
2 / Inappropriate Social Behaviour
3 / Potential for Aggression or Violence
4 / Medical Illness
5 / Medications
6 / Harm to Self
7 / Nutrition/Diet
8 / Isolation
9 / Substance Use/Abuse
10 / Hygiene
11 / Compliance with Treatment Plan
12 / Insight
13 / Finances
14 / Victimization and Vulnerability
15 / Physical mobility / transfers
R. GOALS FOR PLACEMENT
Avoid Hospitalization/Institutionalization / Stabilize/Improve social relations
Community Reintegration/Involvement / Reduce impact of psychiatric symptoms
Education or training / Manage health conditions
Employment or volunteering / Reduce harm associated with use of drugs/alcohol
Improvement ADL functioning (basic self-care) / Abstinence
Improve IADL functioning (more complex activities, e.g. money management) / Improve coping skills (e.g., reduce anxiety; strengthen impulse control)
Other: / Other:
S. (FOR CRP REFERRALS ONLY) CLIENT PREFERENCES / NEEDS
Geographic Area / Community
North / Burnaby / New Westminster / Tri-cities / Maple Ridge
South / Delta / Langley / Surrey North / White Rock/South Surrey
East / Abbotsford / Chilliwack / Mission
Priority of Location / 1st Choice / 2nd Choice / 3rd Choice
List Preferred Facilities
Location / Urban Setting Rural Setting Secure Setting (e.g. perimeter fencing)
Rehab Intensity / Intensive PSR Program Rehab Readiness (low key approach) Aging in Place

• Aging in place – older clients that require a low key approach and/or a more secure setting e.g. perimeter fencing
• Rehabilitation readiness – clients that require a low key approach to gain skills to become rehab ready.
• Intensive rehabilitation – clients that are willing and able to work on rehab goals

1