Out-Patient Mental Health Services - ConnexCentral



Out-Patient Mental Health Services

TIMMINS & DISTRICT HOSPITAL

700 Ross Avenue East

Timmins, Ontario P4N 8P2

Telephone: 267-6315 Fax: 264-6525

REFERRAL FORM

To be filled out by the referring physician, nurse practitioner or secretary, and must have the referring physician’s signature. Patients must be 18 years of age or older to access services with the exception of the Eating Disorders Program.

Date: Family Physician:

Name: D.O.B.: Chart #:

Address

Postal Code: HCN:

Home #: Work #: Other #:

Preferred Language: ( English ( French ( Other:

Previous Psychiatric Classification: ( No ( Yes

Chief Complaint:

Factors that should be considered related to the above request:

Please attach a copy of: ( Relevant History ( Medication List

Referring Physician (Please Print & Sign) Phone Number

It is suggested that all patients be encouraged to attend the Transitional Care Program while awaiting services. 

Please inform your patients of crisis services that are available to them in the event that their situation changes while

awaiting services.

FOR O.P.M.H.S. USE ONLY

|APPOINTMENT BOOKED |DATE ENTERED |

DISCLAIMER:

Please be advised that the Outpatient Mental Health Department is not an emergent or acute department. Referrals are screened and distributed based on the information that is provided. Urgency is determined based on a preliminary assessment (intake) and placement on the waitlist is based on urgency of need and availability of service. Please note that the Crisis Line is available 24 hours a day 7 days a week at 705-264-3003 and 1-888-340-3003. The Crisis Team is also available in the emergency department for consultation should a patient require immediate care.

CLIENT CONTACT

|DATE |NOTES |

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|COMMUNITY TREATMENT ORDER: |

|The purpose of a Community Treatment Order (CTO) is to provide a person with a serious mental illness a comprehensive plan of community based treatment or care and |

|supervision that is less restrictive than being detained in a psychiatric facility.  The Community Treatment Order is a doctor’s order that requires the consent of |

|the individual, or their substitute decision maker. There are specific conditions and criteria for being placed on a CTO. |

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|EATING DISORDERS PROGRAM: |

|The Eating Disorders Program is a community based assessment and treatment program.  The program works in collaboration with community agencies to offer services to |

|individuals with an eating disorder.  There is no age restriction for services and self-referrals |

|are accepted. |

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|INDIVIDUAL THERAPY: |

|Our individual therapy is goal-focused.  Treatment is based in CBT and DBT and is tailored to meet the individual needs of the clients we are servicing.  Twenty |

|sessions will be offered to individuals with a mental illness.  Referrals must be from a physician, Nurse Practitioner or a TADH crisis worker. The patient will be|

|booked for an intake assessment and will be placed in order that the referral has been received or by acuity upon assessment at the intake level. |

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|OVERCOMING ANXIETY, PANIC & PHOBIA PROGRAM: |

|This program is for adults suffering from anxiety, panic & phobia. It is a solution focussed program designed to help clients better manage and cope with their |

|anxiety and related symptoms. It is offered once a week for a period of 10 weeks. |

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|PSYCHIATRY SERVICES: |

|Psychiatric evaluations are available upon the request of a physician.  The patient will be booked for an intake assessment and will be placed in order that the |

|referral has been received or by acuity upon assessment at the intake level. |

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|TRANSITIONAL CARE PROGRAM: |

|The goal of the Transitional Care Program is to offer services to individuals who are just leaving hospital and transitioning home, or who are awaiting services |

|and needing extra support. Our Transitional Care Program is offered in a small-group format.  It is a four week program offered Tuesday, Wednesday and Thursday |

|from 9:00 am until 2:00 pm where individuals with a mental illness can learn a variety of coping strategies and can participate in discussions related to mental |

|health and wellness.  Lunch is offered during this program as well as transportation assistance.  Patients can self-refer and can begin the program at any stage. |

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|CRISIS SERVICES: |

|Patients needing crisis support can contact our Cochrane District Crisis Line at 1-888-340-3003. Crisis workers are available to assess individuals 24 hours a |

|day/7 days a week through the emergency department of the Timmins and District Hospital. |

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Revised 31.10.13

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PCS-0443-1113ab

PCS-0443-1113b

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