Process - Physician - Fraser Health Authority

REFERRAL FORMEARLY PSYCHOSIS INTERVENTION (EPI) PROGRAMBurnaby, New Westminster, Tri-cities, Maple Ridge or Pitt MeadowsREFERRAL CRITERIA: Age 13 – 30 with suspected or first episode psychosis(Please note that substance use does not disqualify from referral).Check all that apply:Suspected PsychosisDelusionsHallucinationsDisorganized speechFamily history of psychotic disorder & serious psychosocial deteriorationGrossly disorganized behaviourNegative symptoms - e.g. flat affect or avolitionOTHER CONCERNS:_____________________________________________________________________________________________________________________________________________________________________________________________Referred By: _______________ Phone: _______________ DATE: ______________CLIENT’S LEGAL NAME: _______________________________________________D.O.B: __________________ M F PHN: ______________________ADDRESS:____________________________________________________________PHONE: ______________________________________________________________NEXT OF KIN:_________________________________________________________FAMILY PHYSICIAN: _____________________________ Phone: ______________PLEASE FAX REFERRAL TO: 604 – 520 – 4871EPI Intake Clinician will contact client to arrange initial assessment andconsultation with one of the EPI Psychiatrists.TO CONTACT EPI INTAKE CLINICIAN CALL: 604 – 777 - 8386Early Psychosis Intervention (EPI) ProgramRoyal Columbian Hospital, 4th Floor - 260 Sherbrooke Street, New Westminster, B.C. V3L 3M2