Physician/Primary Health Care Provider (PHCP) Referral Form

Developmental Disabilities Service

❑ Referral

❑ Re-Referral (Please complete Section A and B only and attach note including any new pertinent information)

Please include any clinical information you may have. Incomplete forms will NOT delay the referral process.

PHCP Name:______PHCP Phone #: (___)______

Mailing address: ______Fax #: (___)______

Patient’s Name: ______DOB______❑Male ❑ Female

(Last/First) (y/m/d)

Address: ______

(street) (city) (postal code)

Phone #.: (_____)______Health Card #:______

Emergency Contact Name/relationship: ______Phone#: (___)______

Is patient aware of referral? ❑ Yes ❑ No

Has a formal assessment and declaration of permanent incapacity, a process during which a POA (or PGT) becomes the official SDM, been completed? ❑ Yes ❑ No ❑ Unknown

Is the patient capable to consent to treatment? ❑ Yes ❑ No ❑ Unknown

If No, Substitute Decision Maker is: ______SDM Phone #:(___)______

Chief Complaint/Reason for Psychiatric Assessment: ______

When did symptoms begin? ______

Describe symptoms when unwell?______

______

Any aggravating factors? ______

______

Alleviating factors? ______

Psychiatric History

Current psychiatric involvement? ❑ Yes ❑ No Psychiatrist’s Name:______

Current psychiatric diagnosis: ______

Date / Past Diagnosed Mental Illness(es) / Doctor

Degree of Developmental Disability: ❑ Mild ❑ Moderate ❑ Severe ❑ Profound

Has a psychometric assessment been completed? (IQ testing)❑ Yes ❑ No *If Yes, please include report if able

1. Is patient able to describe symptoms? ❑ Yes ❑ No ❑ Some

2. Does patient have understanding of diagnosis? ❑ Yes ❑ No ❑ Some

3. Does patient understand his/her intervention(s)? ❑ Yes ❑ No ❑ Some

How does patient describe any of above 3 questions? ______

______

Has patient visited the ER in the past year?❑ Yes ❑ No If yes, please list ______

______

Past Psychiatric Hospitalizations (attach sheet if needed)

Facility / Admission Date / Discharge Date / Reason / Diagnosis

Past Medical/Surgical Hospitalizations (including pregnancies)

Facility / Admission Date / Discharge Date / Reason / Diagnosis

Health History (*Attach most recent labwork, include abnormal blood work, and any imaging reports to speed up the processing of this referral)

Any history of:Yes No If yes, date & description

Seizure Disorder❑ ❑______

Dementia (Alzheimer’s, Lewy body, Frontal lobe)❑ ❑______

Neurological Problems (Tourette’s, head injury)❑ ❑______

Cardiovascular Conditions❑ ❑______

Respiratory Conditions (sleep apnea, asthma)❑ ❑______

GI Complications (GERD, H Pylori) ❑ ❑______

Genitourinary Conditions❑ ❑______

Skin Conditions❑ ❑______

Musculoskeletal Conditions (Scoliosis)❑ ❑______

Endocrine (Thyroid, Diabetes, Cirrhosis)❑ ❑______

Hypertension ❑ ❑______

Impaired Vision❑ ❑______

Impaired Hearing❑ ❑______

Dental Problems❑ ❑______

Genetic Conditions❑ ❑______

Past Reportable Diseases (Hep, HIV)❑ ❑______

Risks (self abuse, suicide attempt, legal, homeless)❑ ❑______

Drug Use (alcohol, tobacco, cannabis, caffeine) ❑ ❑______

Cancer❑❑______

Sleep Problems (insomnia)❑ ❑______

High Cholesterol ❑ ❑______

Pregnancy❑ ❑______

Other (please describe) ______❑ ❑______

Medication Contraindications: ______

Height: ______Weight (+ date taken):______BP______Allergies: ______

Past Psychotropic Medications:

Drug Name / Dose/ Time(s) Taken / Date Started / Date Discontinued / Reason for Discontinuation / Was it Beneficial?
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown

Current Medications: *Attach extra sheet if necessary

Including any prn/over-the counter/herbal/supplementsthe patient takes. *Provide a print out from the pharmacy if easier/able.

Drug Name / Dose/ time(s) Taken / Date Started / Is it Beneficial? / List any side effects noted by patient/ care provider
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown
❑Yes ❑ No ❑ Unknown

Pharmacy:______Phone No:______

** Primary Care of Adults with Developmental Disabilities Canadian Consensus Guidelines are available for reference @

Completed by (if other than family physician):______Date Completed: ______

Please Fax/Send to:

❑Enza Dallaire ❑Kim McEntee

Developmental Disabilities Service

In partnership with

CMHA Cochrane Timiskaming Branch

CMHA Cochrane Timiskaming

330 Second Ave., Suite 201

Timmins, ON P4N 8A4

705-267-8100

705-267-8202 Fax

Please have your service provider/care provider complete the following intake package

Developmental Disabilities Service – Intake Package

❑Referral ❑Re-referral

❑Please indicate if assistance is requested to complete paperwork

Client’s Name:D.O.B. (yy/mm/dd):

Address: ______

(Street/Box No., if appl./City/Postal Code)

Telephone No.: _(___)______Health Card# ______

Family Doctor/Primary Care Provider: ______

Tel. No.:__(___)______Fax No.: __(___)______

Mailing Address: ______

(Street/P.O. Box/City/Postal Code)

Referred by:______

(Name/Agency)

Tel. No.:__(___)______Fax No.: __(___)______

Address: ______(Street/City/Postal Code)

1. Is the client aware of the referral? ❑Yes ❑No

2. Is client able to make their own treatment decisions for themselves? ❑Yes ❑No

a) If not, who makes the treatment decisions for the client? ______

b) If so, has this person been legally appointed as the Substitute Decision Maker (SDM)?❑ Yes ❑No

Contact: ______

* See education form enclosed. If you have any questions regarding this section, further discussion is available upon intake interview with clinician.

3. Has client had eligibility confirmed for MCSS services at the DSO? ❑Yes ❑No

4. Has an application package been completed at the Developmental Services Ontario (DSO)?

❑Yes ❑No If yes, please enclose copy of Assessor Summary Report from DSO.

5. Has a Functional Behavioural Assessment (FBA) been completed? ❑Yes ❑No

If Yes, date: ______(yy/mm/dd) *Please attach copy orlist name of Assessor/Agency:

______Phone #:_(___)______

6. Has an Ontario Common Assessment of Need (OCAN)-self assessment been completed? ❑Yes ❑No

-staff assessment been completed? ❑Yes ❑No

If Yes, date______(yy/mm/dd) Contact person: ______Phone #:(___)______

Client Identification: *Please select one from each category below.

Gender:

❑Male ❑Female❑Other❑Declined to answer ❑Unknown

Preferred Language:

❑English ❑French ❑Other: ______

Income Source:

❑ODSP ❑Employment ❑Family ❑Other❑Declined to answer ❑ Unknown

Aboriginal Origin:

❑Aboriginal❑Non-Aboriginal❑Declined to answer ❑Unknown

Marital Status:

❑Single ❑Married/common law ❑Partner/significant other❑Divorced ❑Widowed❑Separated

❑Declined to answer❑Unknown

Citizenship Status:

❑Canadian❑Permanent Resident❑ Temporary Resident❑Refugee ❑Declined to answer ❑Unknown

Living Arrangements

A. Does client live with anyone?:

❑Self ❑Spouse/partner❑Spouse/ partner & others❑Children ❑Parents ❑Non-relatives ❑Relatives ❑ With Others (complete Part B)

Living Arrangements continued:

B. If you indicated lives “with Others” please identify corresponding category:

❑Approved homes & Homes for Special care ❑Correctional/probation facility❑Domiciliary hostel

❑General hospital ❑Psychiatric hospital❑ Other specialty hospital❑Long term care facility/nursing home, ❑No fixed address ❑Hostels/shelter ❑Private house/apartment – owned/market rent

❑Municipal non-profit housing❑Private non-profit housing❑Private house/apartment – other/subsidized

❑Retirement home/seniors residence ❑ Boarding house❑Supportive housing –congregate living

❑Supportive housing- assisted living ❑Unknown ❑Client declined to answer ❑Other ______

Waitlists:

1. a. Is client on waitlist for higher/alternate level of care? ❑Yes ❑ No If Yes, how long? ______

b. If Yes, why?:______

2. During this time, were there any experiences with: ❑ ER visits ❑ Legal difficulties

❑Out of region placements ❑ Hospitalizations❑ Use of specialized accommodations

Employment Status:

❑ Independent ❑ Assisted/supportive ❑ Sheltered Workshop ❑ Non-Paid work ❑ Casual sporadic

❑ Alternative businesses ❑No Employment- other activity ❑ Declined to answer

❑No Employment of any kind ❑ Unknown

Reason for Psychiatric Referral/Presenting Issues: ______

______

A. Possible Issues:

❑ Activities of daily living❑ Attempted suicide❑ Educational❑ Financial ❑ Housing

❑ Substance Abuse issues ❑ Physical Abuse❑ Legal❑ Sexual Abuse ❑ Problems with Addictions

❑Threat to Others❑ Threat to Self❑ Symptoms of Serious Mental Illness ❑ Problems with Relationships

❑ Occupational/Employment/Vocational❑ Other______

❑ Medication review❑ Diagnosed with an Autism Spectrum Disorder

❑ Significant Life Events (select all that apply):

❑ Change in primary staff ❑ Recent completion of school ❑ Change in roommate

❑ Move of residence/home ❑ Lost job/ financial crisis ❑ Relationship issues

❑ Serious illness/loss ❑ Legal issues ❑ Other ______

C. Symptom Checklist: *Indicate when did symptoms begin? ______

❑Agitation ❑ Social withdrawal ❑ Lack of spontaneity ❑ Apathy ❑Grandiosity ❑ Physical symptoms

❑Delusions ❑ Hallucinations ❑ Poor communication skills ❑ Difficulty in abstract thinking ❑ Hostility ❑ Stereotype thinking ❑ Emotional unresponsiveness ❑ Lack of drive or initiative ❑ Suspiciousness

Current Diagnosis ______

______

Psychiatric History:

1. Has client been hospitalized due to mental health issues during the past two years?

❑ Yes ❑ No❑ Declined to answer ❑ Unknown *If Yes, Total # of admissions: ______

2. How many times has the client visited an Emergency Department over the past 6 months for mental

health reasons? ❑ None ❑ 1 ❑ 2-5 ❑ 6 or more ❑ Declined to answer ❑Unknown

3. Have there been other hospitalizations (for possible medical reasons)? ❑ Yes ❑ No

If Yes, briefly state reason & year______

______

Family History: *indicate relationship to client and diagnosis

Do you know of any biological relatives who have a history of:

❑ Mental illness ______

❑ Major medical illness ______

❑ Genetic / neurological diorder______

❑ Severe substance abuse ______

❑ Suicide attempts______

❑ Psychiatric hospitalizations ______

❑ Developmental Disability ______

LEGAL HISTORY:

A)Does client currently have any legal issues? (select one):

❑ Civil❑ Criminal ❑ None❑ Declined to answer❑ Unknown

B) Current legal status (check all that apply):

Pre-ChargeOutcomes

❑ Pre-charge diversion ❑ Charges withdrawn

❑ Court diversion program ❑ Stay of proceedings

❑ Awaiting sentence

Outcomes continued

Pre-Trial ❑ NCR (Not criminally responsible)

❑ Awaiting fitness assessment ❑ Conditional discharge

❑ Awaiting trail (with or without bail) ❑ Conditional sentence

❑ Awaiting criminal responsibility assessment (NCR) ❑ Restraining order

❑ In community on own recognizance ❑ Peace bond

❑ Unfit to stand trial ❑ Suspended sentence

Custody Status Other

❑ORB detained –community access ❑No Legal problem (includes absolute discharge

❑ORB conditional discharge & time served- end of custody)

❑On parole ❑ Declined to answer

❑On probation ❑ Unknown

Background:

Where was client born and raised? ______

Pregnancy:

Duration (in months): ______Any complications? ❑ Yes ❑ No *If Yes, please describe:______

Delivery:

❑ Spontaneous❑ Induced ❑ Caesarean Birth Weight: ______lbs ______oz

Were there any complications?❑Yes ❑No If yes, please describe: ______

______

Milestones:

Please indicate at what age (approximately) each of these milestones was reached:

Sat up:______Walked: ______Talked: ______Toilet Trained: ______Puberty: ______

Please describe client’s childhood temperament/behaviour: ______

______

Educational History: (select one)

❑No formal schooling❑ Some Elementary/junior high ❑ Some secondary/High

❑Secondary/High ❑ Some College /University ❑ College or University

❑Declined to answer ❑Unknown

❑Currently attending school

Childhood Illnesses: (e.g. Meningitis, Measles, Mumps) ❑Yes ❑ No *If yes, please indicate illness and approximate age it occurred: ______

OTHER:

1. a. Does the client have any children? ❑ Yes ❑No

b. If yes, please provide list (include present age) and describe relationship: ______

2. a. Father’s Name: ______❑ Current ❑Past ❑No involvement with the client

b. Mother’s Name: ______❑ Current ❑Past ❑No involvement with the client

c. Number of Siblings: ______

3. Describe client’s relationship with family members: ______

4. Briefly describe relationships with significant others, including friends, siblings and other primary

support providers: ______

5. Describe hobbies/interests: ______

6. Describe likes/dislikes: ______

7. Describe spiritual needs: ______

8. Describe client when well: ______

9. Describe goals/ hopes for the future: ______

10. What are the perceived needs in order to get there? ______

11. How does the client view his/her mental health? ______

12. Is culture (heritage) an important part of the client’s life? ______

Current Medications: Including any prn/over-the counter/herbal/ supplementsthe client takes. (Attach extra sheet if necessary).

Drug Name / Dose/Time Taken / Date Started / Is it Beneficial? / List any side effects
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown
❑Yes ❑No ❑Unknown

Pharmacy:______Phone No: (___)______

1. Does the client understand the reason(s) for taking his/her current medication(s)? ❑ Yes ❑ No ❑ Some

2. Are the above medication(s) taken as prescribed? ❑ Yes ❑ No ❑ Some

3. Is assistance needed/provided to take above medication(s)? ❑ Yes ❑ No ❑Some

Agency Involvement(s): Please describe any other services/agency currently involved:

Name of Service/Agency / Type of Assistance / Length of Involvement / Contact Person/Number

Additional Information: ______

______

Thank you. Developmental Disabilities Service (DDS)

Please send/fax to

❑Enza Dallaire ❑Kim McEntee

Developmental Disabilities Service

In partnership with

CMHA Cochrane Timiskaming Branch

CMHA Cochrane Timiskaming

330 Second Ave., Suite 201

Timmins, ON P4N 8A4

705-267-8100

705-267-8202 Fax

OFFICE USE ONLY

Date completed referral received: (yy/mm/dd) / Date of first communication with referral source: (yy/mm/dd) / Received by (clinician): / Date print out of the pharmacy medication listing received: (yy/mm/dd)

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Physician/Primary Health Care Provider (PHCP) Referral Form

Client’s Name:______D.O.B. (yy/mm/dd):______

Client’s Name:D.O.B. (yy/mm/dd):