Process - Physician - Fraser Health Authority

Early Psychosis Intervention Programc/o Peace Arch Hospital15521 Russell AvenueWhite Rock, BC V4B 2R4Telephone: (604) 538-4278Fax: (604) 538-4277GP Referral FormFamily Doctor: _______________________Billing No.___________Tel. No.___________________Fax. No.________________ Address:________________________________________________Date:____________________ (dd/mm/yy)Client Name:_________________________________ Date of Birth:______________(dd/mm/yy)PHN:_________________________ Client Telephone No.______________________________Client Address: ________________________________________________________________Current Medication___________________________________________________________________________________________________________________________________________Referral information: Relevant history/ presenting problems/ known risks.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ No prior treatment for psychosis. Client aware ofreferral Fax to EPI Intake: 604-538-4277