Mental Health Referral Form

Referral Source Information

* Referral Source Type Select one... Physician Nurse practitioner Walk-in clinic Community health centre Hospital Other

* Date of Referral

* Referral Contact Name

* Phone
xxx-xxx-xxxx

Ext.

Fax
xxx-xxx-xxxx

* Referral Address

* Referral City

* Referral Postal Code

Billing Number

Client Information

* First Name

* Last Name

* Date of Birth Month... JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day... 12345678910111213141516171819202122232425262728293031 Year... 2023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903

Health Card Number

* Address

* City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln

* Postal Code

* Phone
We can text this number

* Email
We can follow-up using email

* Gender Male
Female
Prefer not to say
Other:

Age at onset of mental illness

Age of first psychiatric hospitalization

Reason for most recent hospital visit/admission:

Reason for Referral

Psychiatric and Medical Diagnoses

Diagnostic Category

• Adjustment disorders
• Anxiety disorders
• Delirium, Dementia, Amnestic, and cognitive disorders
• Developmental delay
• Disorders of childhood / adolescence
• Dissociative disorders
• Eating disorders
• Factitious disorders
• Impulse control disorders not elsewhere classified
• Mental disorders due to general medical conditions
• Mood disorders
• Personality disorders
• Schizophrenia and other psychotic disorders
• Sleep disorders
• Somatoform disorders
• Substance related disorders
• Unknown or service recipient declined

Risk Factors

• Command hallucinations
• Danger to others
• Danger to self
• Fears consequences
• Homicidal thoughts
• Impulsive behaviour
• Medication compliance
• Poor social support
• Risk of falls
• Self-harm
• Suicide attempts
• Suicidal ideation
• Violent intention
• Willing to accept help
• Substance Use, specify:

Notes

Services Requested

Note: Niagara Region Mental Health will assess the needs of the patient and determine which service is most appropriate for that individual.

• Assertive community treatment team
• Case management
• Early psychosis intervention
• Geriatric case management
• Youth mental health and addiction service

---

Consent

• Client has verbally consented to the disclosure of their personal health information for the purpose of a referral to Niagara Region Mental Health
• I agree to receive fax and/or email communication about this referral from Niagara Region Mental Health

Supporting Documentation

Provide any documentation below that is relevant. Only PDF, JPG, DOC(X), XLS(X), PNG, PDF, TXT files will be accepted. File sizes can be no more than 5 MB per file, 10 MB total.

Most recent psychiatric consultation report

List of current medications

Discharge summary

Most recent psychiatric consultation report

Blood work in the last six months

Consultation notes in the last six months

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.