CAMH REFERRAL - INFORMATION AND INSTRUCTIONS

If you have any questions about the referral process, please call Access CAMH at 416-535-8501, press 2.

A physician referral is required for the majority of services at CAMH. A physician referral is preferred for the following services:

• Geriatric Mental Health Service (including Memory Clinic) • Schizophrenia Service (STARS)

Please FAX completed CAMH Referral form to: 416-979-6815 *For Telepsychiatry, please fax the form to: 416-260-4186 *For Sexual Behaviour Clinic only, please fax the form to: 416-260-4187

Those seeking addiction and/or substance use assessment and treatment can self-refer by calling Access CAMH (416-535-8501, press 2).

QUALITY CARE In order to help us provide the best care, please include the following (if possible):

• Relevant lab and test results (e.g., therapeutic drug levels) • Medication sheet • Previous psychiatric consultations or discharge summaries • Medical reports • Physical findings • Psychological reports

Please include a signed Consent for Disclosure of Personal Health Information form, if necessary. If your client is in need of immediate help, please direct them to the nearest emergency department or call 911.

Please note: At CAMH, we integrate clinical care and research to improve the prevention, diagnosis, and treatment of mental health and addiction issues. Clients/patients are key to this goal and may be invited to participate in research.

Instruction page - CAMH Referral F0102-20160519

This page not to be filed on CAMH client/patient health record

CLIENT/PATIENT INFORMATION REFERRAL SOURCE INFORMATIONLegal name: Name:

(last name, first name)

(last name, first name)

Preferred name (if applicable):

Check one: PsychiatristNurse PractitionerFamily PhysicianOther:

Mother's maiden name: Tel:

Date of birth: Fax:

(dd/mm/yyyy) E-mail address:For persons 16 years and older, consent is required for assessment to be completed. Please ensure you have spoken to the person about the referral. Is your client/patient aware of this referral?

Address:

Yes No If no, please explain: Billing number (if referred by physician): What is your client's/patient's gender? Check ONE only:

Female MaleTrans - Female to MaleIntersexPrefer not to answerDo not know

Trans - Male to FemaleOther (please specify)

Is client's/patient's current psychiatrist aware of referral?

Yes No Unknown Does not have psychiatrist

If Yes, name of psychiatrist:

(last name, first name)

Telephone number(s) (specify home, office, cell, etc.) CLIENT/PATIENT ETHNICITY INFORMATIONTel: Which of the following best describes client/patient racial or ethnic group?Tel: Check ONE only.

If you are able to advise, please confirm if confidential messages can be left at the numbers provided above:

Yes No Details:

By listing an e-mail, the referral source confirms that the client consents for CAMH to e-mail appointment details and is aware that e-mail is not entirely secure. CAMH will refrain from sending unrequired personal information until e-mail addreses and consents are verified.E-mail address:

Address:

Health card #:Version code: Expiry date:

(dd/mm/yyyy)Is there a need for an interpreter (e.g., for sign language or other language)?

Yes No If Yes, please specify:

ALTERNATE CONTACT INFORMATION (CLIENT/PATIENT OR LEGAL GUARDIAN CONSENT MAY BE REQUIRED)

Is there anyone other than the client/patient that we shouldcontact? NoYes

(last name, first name)

Relationship to client/patient:

Tel: Tel:

GUARDIAN AND CUSTODY STATUS (IF APPLICABLE) 1. Guardian name:

Custody Status: (both parents need to be aware and consenting to the assessment)

Joint CustodyLives with both parentsSole custody

Other (CAS/relative)Client lives independently

CAMH REFERRAL FORMDate of referral (dd/mm/yyyy):

Asian - East (e.g., Chinese, Japanese, Korean)Asian - South (e.g., Indian, Pakistani, Sri Lankan)

Asian - South East (e.g., Malaysian, Filipino, Vietnamese)Black - African (e.g., Ghanaian, Kenyan, Somali)Black - North American (e.g., Canadian, American)

Black - Caribbean (e.g., Barbadian, JamaicanFirst Nations - Non-statusFirst Nations - StatusIndian - Caribbean (e.g., Guyanese with origins in India)Indigenous / Aboriginal not included elsewhere

InuitLatin American (e.g., Argentinean, Chilean, Salvadorian)MétisMiddle Eastern (e.g., Egyptian, Iranian, Lebanese)White - European (e.g., English, Italian, Portuguese, Russian)White - North American (e.g., Canadian, American)Mixed heritage (e.g., Black-African and White-North American) (Please specify)

Other(s) (Please specify)

Prefer not to answerDo not know

Telephone #:2. Guardian name: Telephone #:

Client/Patient ID Label

(For CAMH use only)

Page 1 of 2 F0102-20160519

Chart Tab: Referral/Intake

Client/patient name:

1. REASON FOR REFERRAL (e.g., consultation, goals for assessment, treatment) Why are you referring the patient now? (e.g., current symptoms, presenting problems, history)

2. SUBSTANCE USE (current substances, amount, frequency of use, etc.): Does client/patient want help with this issue? Yes No

RISK ISSUE CHECK IF YES, WHEN? DETAILS

Suicide attempt / ideation Yes No

Deliberate self-harm Yes No

Violent behaviour Yes No

Legal involvement Yes No

Fire Setting Yes No

3. RISK ISSUES

4. MEDICATIONS (psychiatric and non-psychiatric - attach additional information if needed)MEDICATION CURRENT PAST DOSE / FREQUENCY RESPONSE & ADVERSE EFFECTS

5. AGENCIES, HOSPITALS OR THERAPIES INVOLVED WITHIN THE PAST TWO YEARS

6. RELEVANT MEDICAL / DEVELOPMENTAL HISTORY (e.g., disabilities, intellectual delay, autism, allergies, endocrine, neurological, respiratory, cardiac, metabolic or other issues)

Completed by:

(print name and credentials) (signature) (dd/mm/yy)Date:

When completing electronically, the form should be printed, signed and faxed to CAMH.

Client/Patient ID Label

(For CAMH use only)

Page 2 of 2 F0102-20160519

Chart Tab: Referral/Intake