Mental Health Referral Form printable pdf download

Mental Health Referral Form

Referral form

Phone: 604-875-2345 ext 5332

Fax: 604-875-2099

Date of Referral (dd/mm/yyyy): _____/_____/_______

INCLUSION CRITERIA:

Age between 12 and 24

Evidence of current mental health symptoms

Evidence of problematic substance use symptoms within the past 6 months

Evidence of moderate to severe functional impairment in 1 or more of the following: school, work, family life, peer

relationships, legal, housing, or self care

Client is aware of referral and willing to participate in the concurrent disorders consultation

REASON FOR REFERRAL:

Diagnostic assessment

Treatment recommendations

Limited Treatment

CLINICIAN INFORMATION:

Referring Practitioner:

___________

PSYCHIATRIST

PEDIATRICIAN

NURSE PRACTITIONER

Phone #:

Billing #:

Will you be doing follow-up of patient?

Yes

No If not, who?

CLIENT INFORMATION:

Name:

(Last Name)

(First Name)

(Initials)

PHN:

DOB (dd/mm/yyyy)

______

Address: __________________________________________________________________________________

Phone (H):________________________

(C):__________________________

Email: ___________________________________________________________

bcmhsus.ca | Provincial Youth Concurrent Disorders Program, 5

Floor, Building 77, 4500 Oak Street, Vancouver, BC V6H 3N1

Tel: 604.875.2345 Ext 5332 | Fax: 604.875.2039 Intake Fax: 604.875.2099

Revised: 9/19/2014

Mental Health Referral Form