Intake Referral Form
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1
2Child Youth & Family Mental
Intake Referral Form
Health Services
Service requested by Child/Youth, Family & Community:
☐ Inpatient
☐ Outpatient
☐ Parent Connect (for CYFMHS use only)
MANDATE
The primary mandate of Child, Youth & Family Mental Health Services is to provide tertiary services to children, youth and
their families throughout Vancouver Island and the Gulf Islands
In most cases it is expected that mental health assessment and treatment has been initiated in the home community and
referrals are made due to a need for more intensive multidisciplinary assessment and/or treatment on an inpatient or an
outpatient basis
The ongoing involvement of community physicians and mental health professionals is essential to support the continuing
needs of these clients. Our goal is to communicate with families and involved professionals throughout our process of
assessment and treatment and we encourage you to contact us
REFERRAL PROCESS
1.
Complete two-page form (please print) and fax to (250) 519-6789. The Consent must be signed by the legal guardian
and child 12 years and older before the referral will be considered
2.
If you wish to discuss the referral before submitting, phone Intake (250) 519-6720 or (250) 519-6794 or CYFMH Reception
(250) 519-6908
3.
Additional documentation in regard to program admission criteria may be requested. Relevant reports and assessment
documents must be faxed to CYFMHS Intake (250) 519-6789. Eligibility criteria exist for all programs
4.
Please make requests for urgent Ledger SCU inpatient admissions directly by phoning (250) 519-6720 or (250) 519-6794
Patient Information:
Full Legal Name:
Preferred Name:
DOB:
Current address:
City:
Province:
Postal Code:
☐ Prefer not to disclose
Phone:
Cellular:
Gender:
Family Physician:
Last Physical Exam:
Provincial Health Number:
School:
Phone:
Parent/Guardian Information:
Legal Guardian Name:
Current address:
Relationship:
City:
Province:
Postal code:
Phone:
Child resides with:
Relationship:
Consent:
I__________________________ (Legal Guardian) and ______________________ (Child/Youth 12 years and older)
Give consent for CYFMHS employees to receive and share information related to the mental health assessment and
treatment needs of:
____________________________________with other professionals in order to facilitate the provision of continuing care.
Signature of Legal Guardian:______________________________________________ Date:_____________________
Signature of Child:______________________________________________________ Date:_____________________
Signature of Witness:_____________________________________________________Date:_____________________
Referring Physician or Mental Health Clinician Information:
Referring physician/MH Clinician name:
Billing number:
Current address:
City:
Province:
Postal Code:
Phone:
Fax:
This form can be completed by a physician or mental health clinician only; completion of this form does not guarantee service
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HR-177-05/SW-BV/R: 04/16
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