CMHA Lambton-Kent – Mental Health for All



-5715014287500309753010795Single Point Access For Mental Health Referrals00Single Point Access For Mental Health Referrals ? left202565Is this a d/c referral from hospital - ? Yes ? No00Is this a d/c referral from hospital - ? Yes ? NoPsychiatry (Mental Health First Response Team)? Primary Health Care (Rapid Assessment Intervention Treatment) **GMHOT Psychiatry Consult requires Primary Care Referral**? Geriatric Care 65 & Over – Include labs and Medical Hx (Geriatric Mental Health Outreach Team) Section A: Service Request Information and Presenting Issues3048018415Date:(DD/MM/YY) Referral Time: (24 hour time system)Referral Source: ? RAIT/PCP ? MHFRT/Psychiatry ? Geriatric/GMHOTHealth Providers Name: ____________________________ Signature: __________________________ (Please print)Mental Health Diagnosis: Medications:Describe Mental Health and/or Physical Health Concerns: ______________________________________________________________________________________________________________________________________________________________________________Identify areas of risk/concern relevant to this individual or environment: ______________________________________________________________________________________________________________________________________________________________________________00Date:(DD/MM/YY) Referral Time: (24 hour time system)Referral Source: ? RAIT/PCP ? MHFRT/Psychiatry ? Geriatric/GMHOTHealth Providers Name: ____________________________ Signature: __________________________ (Please print)Mental Health Diagnosis: Medications:Describe Mental Health and/or Physical Health Concerns: ______________________________________________________________________________________________________________________________________________________________________________Identify areas of risk/concern relevant to this individual or environment: ______________________________________________________________________________________________________________________________________________________________________________36881712082800049856620828000178308020383600107823022352000109728012890500Section B: Personal Information495308891Legal Client Name: Pronoun: _____________Preferred Name: ______________________________________ Indigenous Worker Preferred: Yes ? D.O.B. ___________ (DD/MM/YYYY) Age: ____ Health Card #: __________________ Version Code ______Address: _________________________________ City: ____________ Postal Code: _____________Phone:__________________________ Okay to leave message Yes ? No ?Emergency Contact Name: ___________________________ Phone: ____________________________SDM or POA: _______________________ Relationship: _______________ Phone: ________________Address: ___________________________________ City: ____________ Postal Code: ______________Okay to leave message Yes ? No ?00Legal Client Name: Pronoun: _____________Preferred Name: ______________________________________ Indigenous Worker Preferred: Yes ? D.O.B. ___________ (DD/MM/YYYY) Age: ____ Health Card #: __________________ Version Code ______Address: _________________________________ City: ____________ Postal Code: _____________Phone:__________________________ Okay to leave message Yes ? No ?Emergency Contact Name: ___________________________ Phone: ____________________________SDM or POA: _______________________ Relationship: _______________ Phone: ________________Address: ___________________________________ City: ____________ Postal Code: ______________Okay to leave message Yes ? No ?134239021209000Section C: Medical Conditions5905520320Referral Outcome: ____________________________________________________________________Worker Contact: ____________________________________________________________________00Referral Outcome: ____________________________________________________________________Worker Contact: ____________________________________________________________________59055358775Fax completed form to Sarnia CMHA (519) 337-2325CMHA Team Member will respond as soon as possible to begin assessment for service.00Fax completed form to Sarnia CMHA (519) 337-2325CMHA Team Member will respond as soon as possible to begin assessment for service. ................
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