Process - Physician - Fraser Health Authority

MENTAL HEALTH AFTER HOURSPLEASE LEAVE VOICE MAIL TO INDICATETHAT THE REFERRAL HAS BEEN FAXEDPhone: 1-877-384-8062Fax: 604-587-4227CAR 67 (Surrey Only)Phone: 604.599.0502(RCMP Non Emerg)Emergencies 911 Request for Service Alert/Information Only Follow-UpREFERRAL FORMMental Health ServicesCRESST (Surrey)13525 – 98 th Ave., Surrey, BC V3T 1B9Phone: 604.587.4220 Fax: 604.587.4227CRESST (New West)220 Sherbrooke St., N. West, BC V3L 3M2Phone: 604.521.1205 Fax: 604.521.2619CRESST (Abbotsford)33720 McDougall Ave., Abbots., V2S 1W4Phone: 604.870.7583 Fax: 604.852.7102Date Referred: Time: Person & Place Referring: Referring Agency Phone Number:Date of Last Face-to-Face Contact:Client Name: Alias(es): DOB (yy/mm/dd) Sex M FAddress: City: Postal Code: Phone(s) #:Call Blocking: Y NPHN: Next of Kin/Relationship: Phone #:Family Physician:Phone:Psychiatrist:Phone:Mental Health Centre: Mental Health Therapist: Phone:Diaoses:Axis I:Axis II:Axis III:Axis IV: Axis V:For MHAH & Car 67 Only: Last MHC Visit:Next Scheduled Visit:Last Hospitalization:BEHAVIOURSSubstance Misuse: Current Y N History Y NSubstance Used Date Last Used Amount Used FrequencyCurrently Suicidal Y N Plan/Means:Last Suicide Attempt (yy/mm/dd)Details of History of Suicide Attempts:Aggression: Current Aggression? Y N Hx of Violence /Aggression Y NDetails of History of Aggression:(include weapons and method)Date of Last Incident: Does the Client Have a weapon? Unknown Y NFire Setting: Y N Date of Last Incident: Type:Sexual Issues: Y N Date of Last Incident: Type:Legal Issues: Y N Date of Last Incident: Type:07/09 C:\Users\Bruce\Documents\MD-DOC\PSP\Mental Health\Fraser Valley\Cresst referral.doc1