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Intake Coordinator

Outpatient Mental Health Services

Voice Mail:  (416) 469-6310              Fax: (416) 469-6116

In order to ensure his/her motivation and gather more information, it is necessary for the patient

to call, the above number. If it is necessary for us to contact your patient, please indicate:      Yes         No

Patient’s First Name: _________________________ Last Name: _________________________

Address:________________________________________________________________________

__________________________________________Postal Code: _________________________

Phone #_____________________________   D.O.B.      dd       mm     yy         Male      Female

Can a confidential message be left on the patient’s voicemail?     Yes        No  

Has this patient been seen formerly at TEGH Mental Health Service     Yes       No  

Referral Source

Name: _________________________________________________________________________

Address:  _______________________________________________________________________

______________________________________ Postal Code:  _____________________________

Phone:_____________________________________ Fax:  ______________________________

Family Physician  ™           Psychiatrist   ™            TEGH Physician  ™          Other  ™

Your patient should continue under your care for their Mental Health concerns until their assessment takes place. If a crisis situation arises please inform them to go to their closest Emergency Department.

Physician#_________________

Signature:  ____________________________________________________ 

1.      Reason for referral/statement of presenting problem;   

      Consultation  ™   Treatment   ™     Both  ™

__________________________________________________________________________

2.      Current psychiatric presentation (please be specific) 

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

3.     Past and present psychiatric diagnosis and treatments:  Specify all therapies

     and medication prescribed with doses.  Please attach relevant reports.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

4.      Complete the following chart:

Problem	Present		Past		Specify here
	Yes     No		Yes        No
Alcohol abuse/dependence
Violent behaviour
Suicidal ideation
Suicidal attempts
Self-harming behaviour

History of the following:

	Check (Ö )	Give details: when, treatment, medications, etc.
Depression
Anxiety
Psychosis
Characterological
Marital/Family
Sexual abuse

5.      Please indicate any relevant medical history (include medications):

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Please indicate if any of the following are relevant to this referral:

Is there any legal or forensic aspect to this referral?                                   Yes ____  No ____

Is there any matter related to compensation or insurance?                        Yes ____  No ____

Will any reports be sought other than the clinical consultation letter?         Yes ____  No ____   

If yes to any of the above, please provide details:

___________________________________________________________________________

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