Process - Physician - Fraser Health Authority

REFERRAL FORMMental Health and Substance Use ServicesCont'dPage: 2 of 2D. PREVIOUS CONTACTSPREVIOUS CONTACTS WITH HOSPITAL, COMMUNITY MENTALHEALTH AND ADDICTIONS OR FORENSIC SERVICES?HOSPITALMOSTCOMMUNITY MHARECENTCONTACTSSERVICES. FORENSICSERVICESNO YES UNKNOWNIF REFERRAL FROM HOSPITAL, ACTUAL OR EXPECTED DISCHARGE DATE (DD/MM/YY)DATE (DD/MM/YY)DATE (DD/MM/YY)DATE (DD/MM/YY)EXTENDED LEAVENOYES - CERTIFICATE EXPIRY DATE (DD/MM/YY)TO BE COMPLETED WHEN REFERRAL IS MADE FROM HOSPITALS OR OTHER HEALTHCARE PROVIDERSE. MEDICATION AND ALLERGY INFORMATIONCURRENT MEDICATIONS or MAR and/or CURRENT PRESCRIPTIONS and/or PHARMANET PROFILE ATTACHED(including known OTCs, herbals and vitamins)LONG-ACTING NAME DOSAGE FREQUENCYINJECTIBLEMEDICATION WHEN LAST GIVEN (DD/MM/YY) WHEN NEXT DUE (DD/MM/YY)MEDICATION COVERAGE SELF PLAN G OTHER:ALLERGIESALLERGY PROFILE ATTACHEDFOR OFFICE USE ONLY. THIS SECTION TO BE COMPLETED BY MHSU CLINICIANF. MENTAL HEALTH CENTRE FOLLOW UP1st ATTEMPT DATE CONTACT CONTACT NO IF NO REASON:TO CONTACT (D/M/Y) MADE BY SUCCESSFUL YES2nd ATTEMPT CONTACT CONTACT NO IF NO REASON:DATETO CONTACT MADE BY SUCCESSFUL YES3rd ATTEMPT CONTACT CONTACT NO IF NO REASON:DATETO CONTACT MADE BY SUCCESSFUL YESFOLLOW UP DATE LETTER CONTACT NO IF NO REASON:LETTER SENT SENT SENT BY SUCCESSFUL YESINITIAL SCREENINGINTAKEINTAKEDATE (DD/MM/YY) CLINICIAN SIGNATUREFILE OPENEDFILE NOT OPENED / CANCELLEDOPEN DATE(DD/MM/YY)1st APPOINTMENT(IF APPLICABLE)REVIEW DATE(DD/MM/YY)DATE(DD/MM/YY)REASON(S)NOT OPENED