Adult Outpatient Mental Health Services Coordinated Intake Referral Form
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2LHSC PIN if available
_________________________________
ADULT OUTPATIENT MENTAL HEALTH SERVICES COORDINATED INTAKE REFERRAL FORM
•
PHONE: 519 667-6551
FAX: 519 667-6836
*SERVING RESIDENTS OF LONDON & MIDDLESEX COUNTY; AGES 18 to 64*
REFERRALS RECEIVED MONDAY TO FRIDAY 08:30 - 1600
PLEASE PRINT WHEN COMPLETING FORM
PATIENT INFORMATION
REFERRING SOURCE INFORMATION
Name: Last _______________________________________
Referring Physician/
Nurse Practitioner:
________________________________________________
Name: First _______________________________________
Billing Number:
____________________________________________________
DOB (
:
(18 - 64 years)
YYYY/MM/DD)
_______________________________
Phone:
Fax:
_________________________
_____________________________
Health Card #:
VC:
____________________________
__________________
Family Doctor:
same as above
_____________________________
Address:
___________________________________________________________
Are you part of a family health team?
Yes
No
City:
(London-Middlesex)
________________________________________
Does the patient have a current Psychiatrist?
Yes
No
Postal Code:
_______________________________________________________
If yes, specify and give reason for your request:
Current Phone:
____________________________________________________
Psychiatrist Name:
________________________________________________
*Please ensure accuracy of the phone number provided & confirm a
message may be left as patient will be contacted for telephone intake.
Reason:
____________________________________________________________
Special Communication Needs:
Yes
No
______________________________________________________________________
If yes, specify
_____________________________________________________
*Urgent Consults are not provided for patients who
currently have a psychiatrist, urgent concerns should be
*Language/sign interpretation will be arranged by intake if required.
brought to the treating psychiatrist’s attention.
Current Safety Risk Factors
*Please assess and check all that apply
Active Suicidal thoughts
Passive Suicidal thoughts
History of Suicide Attempts
Thoughts to Harm others
History of Violence
Behaviour Influenced by delusions/command hallucinations
Current Intentional Self Harm Behaviours
Current Substance Abuse Substance:
_______________________________________________________________________________________________
Other Please specify
____________________________________________________________________________________________________________________
Please provide any additional details regarding risk and select the level of assessed urgency with respect to risk below:
1
2
3
4
5
(1 = most urgent)
(5 = no risk)
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
If your patient is actively planning suicide or presents with immediate risk to self or others,
the patient should be directed to the Emergency Department at Victoria Hospital for assessment.
Please ensure all patients are provided with the
Mental Health Crisis Service number (519-433-2023) and Emergency resource information.
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NS5497 (Rev. 2015/11/26) Page 1 of 2
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