Process - Physician - Fraser Health Authority

Physician Referral FormFor adults experiencing mild to moderate depression (PHQ-9 range = 5 to 19),with or without anxiety, community coaches provide telephone delivery of abrief, structured, self-help program to improve mental health.Patient Name: ___________________________________________________________Telephone: ______________________________________________________________Date of Birth: _ ___________________________________________________________Please confirm that the patient:Is not cognitively impairedIs not misusing alcohol or drugsDoes not have a personality disorderIs not severely depressed or at risk to self or othersDoes not have a history of bipolar disorder or psychosisIf available, please include the patient’s PHQ-9 score:PHQ-9 ScoreIs the patient receiving medication for:Depression?Yes NoAnxiety?Yes NoWould the patient prefer to access the program in Cantonese?Yes NoReferring Physician and Contact Information:Please transmit referral information to yourBounce Back Community Coach:South Fraser (Surrey, Delta, White Rock,Langley, Abbotsford, Chilliwack, Hope)Phone: 604-543-1373 / Fax: 604-543-1369North Fraser (New West, Tri-Cities, Maple Ridge,Pitt Meadows, Mission, Harrison, Boston Bar)Phone: 604-515-9889 / Fax: 604-524-2870