Referral Form

Referral Form

CRISIS COUNSELLING
(Physician referral not required)
(up to 6 sessions)

MENTAL HEALTH DAY PROGRAM

Morning Program (Early Recovery)
(physician referral required)

Afternoon Program (Middle Recovery)
(12 week program - 5 days a week)

Afternoon Partial Program (Maintenance Recovery)

MENTAL HEALTH COUNSELLING PROGRAM
(physician referral required)
(up to 10 sessions)

REGISTRATION FOR SUPPORT GROUPS

Assertiveness Training Group
(once per week for 10 weeks - twice per year)

Anxiety Education Program
(once per week for 10 weeks - twice per year)

Relaxation
(weekly - ongoing)

MEDICATION CLINIC
(physician referral required)

VOCATIONAL INCENTIVE PROGRAM
(physician referral required)

Is client aware of this referral ? No Yes

Can your patient access an Employee Assistance Program (EAP) ? No Yes

Last Name First Name
Address (Street #) City
Province Postal Code

Phone Number (residence or business)

E-mail

Male? Female Date of Birth Marital Status

Ontario Health Card #

Allergies?

Psychiatric Diagnosis

NOTE: People who present with a serious mental health problem or with psychosocial issues complicated by a mental health problem, will receive priority service.

Symptom Duration

Less than one month

Less than one year

Over one year

Mental Health Issues

Sad/depressed mood

Euphoric/elated mood

Poor/inability to concentrate

Delusions

Hallucinations

Social withdrawal

Negative Statements

Thoughts of harm to self or others

Hopelessness

Anger

Sleep disturbance

Disorganized thoughts

Symptoms of Anxiety

Self deprecation

Psychosocial Issues

Interpersonal conflict

Vocational Issues

Family Issues

Financial Issues

Legal Issues

Unresolved grief

Diagnosis:

Current Medication (s):

Psychiatrist:

Address / P.C.:

Phone:

Family Physician:

Address / P.C.:

Phone:

Date:

Referral Source:

According to Statistics Canada and the Canadian Mental Health Association:

1. One out of every eight Canadians can expect to be hospitalized for a mental illness at least once during his or her lifetime,

2. One and a half million people living in Ontario have some form of mental illness; 38,000 are severely disabled by schizophrenia, affective disorders and other mental illnesses (4.1 per 1,000 population).

The Graham Report, 1988

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