Funding Application For Out Of Province Mental Health And Or Addictions Page 3
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47. The referral for out-of-province treatment must be reviewed with the Regional Director responsible for Mental Health and Addiction
Programs in your regional health authority. The Regional Director contacted:
Name
Health Authority
Phone Number
Date
8. Is your patient a health care provider?
Yes
No
If so, is she/he currently licensed?
Yes
No
MultiAxiAl ForMulAtion
Axis i - clinical disorders / other conditions that may be a focus of clinical Attention
diagnosis code
dsM-iv name
Axis ii - personality disorders / intellectual disability
diagnosis code
dsM-iv name
Axis iii - general Medical conditions
diagnosis code
dsM-iv name
Axis iv - psychosocial and environmental problems - check all that apply and speciFy for any checked item.
Problems with primary support group ______________________________________________________________________________________
Problems related to the social environment _________________________________________________________________________________
Educational problems ____________________________________________________________________________________________________
Occupational problems __________________________________________________________________________________________________
Housing problems _______________________________________________________________________________________________________
Economic Problems _____________________________________________________________________________________________________
Problems with access to health care services _______________________________________________________________________________
Other psychological and environmental problems ___________________________________________________________________________
Axis v - global Assessment of Functioning scale
Score: ____________________________________
Time Frame: _______________________________
HLTH 2809 2010/08/12
PAGE 3 OF 4
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