Mental Health Referral Form

* = Required

Referral Information

* Date of Referral

Client Information

* Date of Birth

* Can we leave a message

* Gender

Identifies as Indigenous

Preferred Language of Service Delivery

For mental health, in the last two years, number of client hospital:

Alternate Contact

Consent and Capacity

Is the client aware of this referral?

Has the client consented to this referral?

Is the client deemed capable of making treatment decisions?

Does client have a substitute decision maker?

Does the Substitute Decision Maker consent to this referral?

Is the client on a community treatment order?

Diagnostic Category

List of Current Medications

MedicationDoseDate Started

Presenting Issues

Risk Assessment

SymptomCurrentLast 5 YearsNotes
Command hallucinations
Danger to others
Danger to self
Fears consequences
Homicidal thoughts
Impulsive behavior
Medication compliance
Poor social support
Risk of falls
Suicide attempts
Suicidal ideation
Violent intention
Willing to accept help

Substance Use and Addictions

SubstanceCurrentLast 5 YearsNotes
(substance name, dose, frequency, and mechanism, such as ingestion, inhalation, injection)
Misuse of prescription drugs
Recreational / street drugs
Other Substance
BehavioursCurrentLast 5 Years 
Other Behaviour  

Other Agencies Involved

CAGE-AID Questionnaire

When thinking about drug use include illegal drug use and the use of prescription drugs other than prescribed.

Do you drink alcohol?

Have you ever experimented with drugs?

Have you ever felt that you ought to cut down on your drinking or drug use?

Have people annoyed you by criticizing your drinking or drug use?

Have you ever felt bad or guilty about your drinking or drug use?

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

Personal Information and Privacy

Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.

Freedom of Information

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email our Access and Privacy Office or call 905-980-6000 ext. 3779.

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