Referral for Ambulatory Mental Health and Addictions Services

INFORMATION FOR REFERRING PROVIDERS: • A physician or nurse practitioner referral is required (self-referral is not accepted) • It is preferred that the referral comes from the treating psychiatrist or physician • The referring physician must accept care after patient has completed the time-limited treatments available in the clinic • This program is not catchment specific • This referral form is. [...] If the patient cannot be reached, the referring provider will be notified. [...] PLEASE NOTE THE FOLLOWING CRITERIA: These criteria are required to receive care from this clinic: a) Referring practitioner agrees to accept patient once psychiatric treatment is complete b) Patient accepts that treatment and services are time-limited c) Patient is 18 years of age or older d) Patient has tried at least one or more guideline concordant psychotropic medication trials and at least on. [...] RISKS AND SAFETY CONCERNS This information is used to optimally plan for the patient’s first appointment and to ensure their safety and the safety of our staff. [...] RISK ISSUES PRESENT PAST DETAILS Y N Y N Legal Involvement Violent Behaviour Suicide Attempts/ Ideation Other Self Harm Behaviour The referring practitioner has reviewed the referral criteria on page one and confirms the client meets the criteria to receive care.