CANADIAN MENTAL HEALTH ASSOCIATION -- METRO TORONTO

Referral Form


 TRANSACTION INFORMATION   
a. Program Number
Phase
Staff Number
b. Transaction Date (Year/Month/Day)
Transaction Time
Transaction Type
c. Client / Referral ID

 IDENTIFICATION SECTION   
d. Legal Surname
Legal First Name
Legal Middle Name
e. Previous or Maiden Name
f. Preferred Surname
Preferred First Name
Preferred Middle Name
g. Sex
h. Date of Birth (Year/Month/Day)
Does this person have a twin?
i Old OHIP Number
New Provincial Health Number
j. Street Address (Line 1)
Street Address (Line 2)
City / Town
Province
Postal Code -
Residence Code
k. Home Phone Number ( ) -
Business Phone Number ( ) - Extn.
Other Phone Number ( ) - Extn.

 REFERRAL INFORMATION   
l. Referral Source
Referral Source - Program
Referral Source - Program Phase
Referring Facility (if applicable)
Number of Prior Referrals
Date of Last Contact (yyyy/mm/dd)
Number of Previous Admissions
Date of Last Discharge (yyyy/mm/dd)
Number of Hospitalizations (2 yrs)
Duration of Hospitalization(s) , , , ,
Number of Police Incidents in last 2 years