Referral Form - North Simcoe Therapy Network Page 2
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1
2Upon Completion Please Fax Front and Back to 705‐481‐1925
or Email a Scanned Copy to clinic@midlandtherapy.com
Psychiatric Referrals Must Be Completed by a Physician
1. REASON FOR REFERRAL (e.g., consultation, goals for assessment, treatment, presenting problems)
2. SUBSTANCE USE (current substances, amount, frequency of use, etc.)
3. RISK ISSUES
4. MEDICATIONS
RISK ISSUE
CHECK IF
IF YES,
DETAILS
MEDICATION
DOSE /
RESPONSE &
YES
WHEN
FREQUENCY
ADVERSE
EFFECTS
Suicide
attempt /
ideation
Deliberate
self‐harm
Violent
5. AGENCIES, HOSPITALS OR THERAPIES
behavior
INVOLVED WITHIN THE PAST TWO YEARS
Legal
involvement
Fire Setting
Completed by:
_________________________ ____________________________
_______________________
Print Name and Credentials
Signature
Date: (DD/MM/YY)
North Simcoe Therapy Network ‐ 11 Mill Street, Wyebridge ON L0K 2E1 – Phone/Fax: 705‐481‐1925 Email: clinic@midlandtherapy.com
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