CATCH
CATCH-H Please complete all sections of the referral and consent forms
FAX TO: 416‐864‐5467
Coordinated Access to Care for the Homeless (CATCH-H)
REFERRAL FORM
Primary, mental health and/or addictions care for people who are homeless and not adequately connected to health services
Client Information:
First Name: _______________________ Last name: _______________________ Alt. Name(s): __________________
Gender: □ Male □ Female □ Transgendered Date Of Birth: M _______ D _______ Y _______________
Phone Number: ___________________ Cell: __________________ Email: ______________________________________
Health Card #: _____________________________________________ Version Code: __________ Province: __________
Person’s physical description: ___________________________________________________________________________
____________________________________________________________________________________________________
Current or last known location/address: ___________________________________________________________________
____________________________________________________________________________________________________
Drop-in(s) or other agencies where this person spends the most time and best times when s/he can be reached at this/these locations: ___________________________________________________________________________________
____________________________________________________________________________________________________
The client has consented for us to contact the following individuals or organizations:
|Telephone number(s) where s/he can be reached|What kind of phone number is this? |Best times when he/she can be reached at this |
| |(e.g., personal, shelter, friend/family, drop-in; |telephone number(s) |
| |provide additional names/information if applicable) | |
| | | |
| | | |
Health Profile:
Mental health (list relevant diagnostic information): _________________________________________________________________________________________ _________________________________________________________________________________________
Physical health (list relevant diagnostic information, inc. communicable diseases, e.g., TB, MRSA, lice, mobility issues): _________________________________________________________________________________________ _________________________________________________________________________________________
Substance use (list substances, IV use if any):
_________________________________________________________________________________________ _________________________________________________________________________________________
Please complete all sections of the referral and consent forms
FAX TO: 416‐864‐5467
Medications (list medications taken, inc. doses and frequency of administration):
_________________________________________________________________________________________ _________________________________________________________________________________________
Medications prescribed by: __________________________________________________________________________
Service Needs:
Does the person have a Family Physician or Psychiatrist? □ Yes □ No
If yes:
Name: _________________________________ Specialty: ___________________________ Phone: _____________________
Name: _________________________________ Specialty: ___________________________ Phone: _____________________
What type of assistance does this client need? (check all that apply)
□ Family physician □ Psychiatrist □ Mental Health case management
Support Services:
Does the person have a case manager or support worker? □ Yes □ No
If yes:
Name: _________________________________ Agency: ___________________________ Phone: _____________________
Name: _________________________________ Agency: ___________________________ Phone: _____________________
Safety Alerts:
History of aggression: □ Yes □ No
If yes, please explain:________________________________________________________________________
________________________________________________________________________________________
If applicable, Probation/Parole Officer name: _______________________________ Phone: ____________________
Other Relevant Information:
_________________________________________________________________________________________ _________________________________________________________________________________________
CATCH-H Please complete all sections of the referral and consent forms FAX TO: 416‐864‐5467
Coordinated Access to Care for the Homeless (CATCH-H)
CONSENT FORM A
Client Consent* to the collection, use and disclosure of Personal Health Information
CATCH-H is a partnership between St. Michael's Hospital, Inner City Health Associates and Toronto North Support Services. These organizations work together and collaborate with other health and social service agencies, such as the Good Shepherd Center and the Parkdale Activity Recreation Center Peer Support Program to help connect people who are homeless to health resources in the community. To protect your privacy, CATCH-H follows the Ontario Personal Health Information Protection Act. None of your Personal Health Information will be collected or shared with any person other than those involved in your care, except with written consent or if required by law.
I consent to collection and use of information (including diagnostic and needs assessments, reports from service providers, discharge plans) between the referring hospital / agency and CATCH-H for the purpose of:
• Coordinating your care between CATCH-H partners
• Assessing your needs
• Developing plans of care and matching to appropriate supports
I understand that I may withdraw my consent at any time by giving notice in writing to my CATCH case manager. Once I withdraw consent, my Personal Health Information shall no longer be shared or disclosed to CATCH partners.
Client Name: _____________________________________________________________________
Client signature: ________________________________
Date (MM/DD/YY): ___________________
*If applicable, Substitute Decision Maker’s (SDM) name:___________________________________________________________
SDM’s signature: ________________________________________ Date (MM/DD/YY): ________________________
CATCH-H Please complete all sections of the referral and consent forms
FAX TO: 416‐864‐5467
Coordinated Access to Care for the Homeless (CATCH-H)
CONSENT FORM B
Client Consent* to the release of information by contact persons or agencies
We would like you to contact the CATCH-H Coordinator with any update about your living situation. You can use a toll-free phone number, 1-877-482-4595, for these phone calls.
In the referral form, you have given us the names and contact information of friends, relatives, service providers or other people who might know where you are if we are not able to get in touch with you when it is time for your follow up appointment. We will be asking these people only about your location and contact information and only when we don’t know where you are and are trying to find you to schedule an appointment. We will tell these individuals that we are trying to get in touch with you for the purpose of helping connect you to health resources, but we will not share any of the information you have provided in the referral form or any other personal information.
I consent to the CATCH-H partners contacting the individuals or organizations I named on the referral form. I authorize these people to release information regarding my up-to-date mailing address and phone number to the CATCH-H partners.
Client Name: _____________________________________________________________________
Client signature: ________________________________
Date (MM/DD/YY): ___________________
Referral Source Information:
I have explained the consent to the client and provided the client and/or SDM with an opportunity to ask questions that I answered.
Name of person making referral: _________________________________________ Date (MM/DD/YY): ________________
Hospital / Agency: __________________________________________ Department: ______________________________
Phone: _________________________ Pager: _________________________ Email: ________________________________
Has the client given consent to this referral being made? □ Yes □ No
*If applicable, Substitute Decision Maker’s (SDM) name:___________________________________________________________
SDM’s signature: ________________________________________ Date (MM/DD/YY): ________________________
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