Selkirk Mental Health Centre

Selkirk Mental Health Centre ABI Transitional Residence Referral Form

Date: ______

Section 1: Personal Data:

Name: Gender:

� Male � Female

Date of Birth (month/day/year): Marital Status:

MB Health #: Occupation:

PHIN #: Treaty #:

Date of Injury or Event: Nature/Type of Injury or Event: � mva (motor vehicle accident) �mva (motorcycle) � mva (on bicycle/pedestrian) � fall Was this injury or event work-related? �assault � sports injury (specify) ______� No � Yes � trauma-other (specify) ______�non-trauma (specify) ______� unknown

Address: Accommodation:

� house �apartment building � supportive housing � rooming house � other (specify) ______

Phone: Present Living Situation: �alone � with others (specify) ______

CR 009B Jan 2011 Section 2: Referral Source

Contact Name/Position: Applicant is currently: � at home Organization: �other (specify) ______

Phone: If applicant is in hospital, please provide: Date of admission: ______Other Phone: Planned date of discharge: ______

Referring Physician: Family Physician:

Address: Address:

Telephone: Telephone:

Signature: Signature:

Billing #: Billing #:

1. Reason for Referral *Referring/Attending Physician reason required

2. Client/Family Goals

3. Urgent Issues and Concerns

CR 009B 2 Jan 2011 Section 3: Service Information

1. Treatment History Including Current Services Program/Facility Dates Involved Contact Name and Phone ______

2. Current Therapy Staff Involved Contact Name Discipline Phone ______

Describe applicant’s level of participation:

3. Follow Up Appointments Booked

� No �Yes �Attached

Dates Purpose/Specialty Contact and Phone # ______

CR 009B 3 Jan 2011 4. Neuropsychological Assessments Completed

� No �Yes �Attached

Date Completed By Whom Phone ______

5. Transportation Needs for Attending Program/Service

� Independent �Assisted �Other

If assisted or other, please specify.

6. Languages Spoken

7. Interpreter Required

� No �Yes

Name Phone (Home and Work) ______

8. Access to Paid Interpreter

� No �Yes

If yes, please provide contact information.

9. Explain applicant’s current tolerance for structured programming, i.e. how many hours can he/she tolerate participating in physical or occupational therapy?

CR 009B 4 Jan 2011 In work or volunteering? Section 3: Social Information

Substitute Decision Maker: Relationship to Applicant:

� No �� Spouse/Partner �Parent Next of Kin/Substitute Decision Maker Name: � Son �Daughter � Sibling �Other

Address: Phone (Home):

Phone (Work):

Enduring Power of Attorney: Advance Directives: � No �� No �

Activated: Activated: � No �� No �

Contact Person (if different from next of kin or substitute decision maker): Name: Phone (Home):

Relationship to Applicant: Phone (Work):

Education/Employment Highest Grade/Level Attended: Employed at Time of Injury or Event:

� No �

When: Type and Duration of Employment:

1. Will family/support network participate in rehabilitation planning and programming? � No �Yes

2. Does family/support network require assistance/education to participate in rehabilitation/support? � No

CR 009B 5 Jan 2011 �Yes 3. Does family/support network agree with discharge to home plans?

� No �Yes

4. Additional Information and Considerations:

5. Community/Region Applicant will Reside in Upon Discharge from ABI Program. Please specify community and health authority.

6. Ideal Living Environment (Independent Home, Group Home, Personal Care Home)

7. Financial Information

Source Initiated Date Submitted Approved �WCB ______� MPIC ______�CPP ______� EI ______�STD ______� LTD ______�Other ______

Please provide Contact Information and Claim Number if applicable:

CR 009B 6 Jan 2011 8. Legal Issues:

9. Professionals/Agencies Currently Involved

Company Contact Phone ______

Section 4: Medical Information Please have each question completed by appropriate discipline if available.

1. Diagnosis (Brain Injury and Other Additional Diagnoses)

2. Seizures � No �Yes

If yes, please include dates and description:

CR 009B 7 Jan 2011 3. Did initial injury cause loss of consciousness? � No �Yes

Coma Length ______

4. Post Traumatic Amnesia � No �Yes If Yes, please provide duration ______

5. CT/MRI Results (or attach report) Please include the date of completion and facility.

6. Past and Relevant Medical History

7. Previous History of ABI � No �Yes

If yes, please describe.

8. Pre-Injury History of Substance Abuse � No �Yes � History not available

CR 009B 8 Jan 2011 9. Current Substance Abuse

� No �Yes � Not known

10. Substance Abuse Treatment Recommended � No �Yes

11. Has the applicant previously participated in any substance abuse treatment programs? � No �Yes Date:______

12. Previous Psychiatric History

� No �Yes

13. Current Psychiatric Status:

14. Does applicant have any allergies? � No �Yes

If yes, please indicate the allergies and care needs if applicable.

CR 009B 9 Jan 2011 15. Please list all current medications and reasons for taking them:

Medication Reason ______

______

16. Medical Staff Involved (family physician, specialists, etc.)

Physician Specialty Phone ______

Section 5: Rehabilitation Placements

1. Number and List all Placement(s) Tried

2. Duration of Placement(s) and Reason for Breakdown

3. Current Viable Post-Discharge Placement Options

CR 009B 10 Jan 2011 4. Does the applicant want to be admitted to the ABI Transitional Residence? � No �Yes

5. Is the family/support system agreeable with admission to the ABI Transitional Residence? � No �Yes

Section 6: Functional Information Please complete the following tables to indicate the applicant’s current level of functioning at time of referral. Please comment on any adaptive equipment applicant requires/utilizes.

Independent Cueing/Safety Concerns Some Assist Required Total Assistance

S Comments: Compiled by: C T Basic Personal Issues: I A S A � OT � RN R � PT � SLP Eating/Drinking � � � � � SW � Other Dressing � � � � (Please Initial) Bathing � � � � Toileting � � � � Bladder Management � � � � Bowel Management � � � � Grooming � � � � Paresis/Paralysis � � � � Medication � � � � Pain/Headaches � � � � Fatigue � � � � Identified risk(s): Sleep Disturbance � � � � S Comments: Compiled by: C T Mobility/Locomotion: I A S A � OT � RN R � PT � SLP Transfers Chair � � � � � SW � Other Transfers Bed � � � � (Please Initial) Transfers Wheelchair � � � � Transfers Car � � � � Transfers Toilet � � � � Transfers Tub or Shower � � � � Walking � � � � Wheelchair � � � � Stairs � � � � Outdoor/Community Mobility � � � � Falls/History of Falls � � � � Identified risk(s): Stamina � � � �

CR 009B 11 Jan 2011 Balance/Dizziness � � � � Independent Cueing/Safety Concerns Some Assist Required Total Assistance

S Comments: Compiled by: C T Communication: I A (completed attached S A � OT � RN R sheets) � PT � SLP Hearing � � � � � SW � Other Vision � � � � (Please Initial) Language, Comprehension � � � � Language, Expression � � � � Comprehension – Visual � � � � Comprehension – Auditory � � � � Expression – Verbal � � � � Expression – Non-Verbal � � � � Reading � � � � Writing � � � � Pragmatics/Conversation Skills � � � � Identified risk(s): Speech Intelligibility � � � �

S Comments: Compiled by: C T Instrumental Needs: I A S A � OT � RN R � PT � SLP Meal preparation � � � � � SW � Other Housekeeping � � � � (Please Initial) Shopping � � � � Identified risk(s): Financial Management � � � �

S Comments: Compiled by: C T Behaviour Issues: I A S A � OT � RN R � PT � SLP Ability to Adjust to Change � � � � � SW � Other Impulse Control � � � � (Please Initial) Mood Disorder � � � � Thought Disorder � � � � Wandering � � � � Aggressiveness � � � � Sexually Inappropriate � � � � Identified risk(s): Suicidal Risk/Ideation � � � �

S Comments: Compiled by: C T Psychosocial Adjustment: I A S A � OT � RN R � PT � SLP Social Interaction � � � � � SW � Other Emotional Status � � � � (Please Initial) Adjustment to Limitations � � � � Identified risk(s): Employability � � � �

CR 009B 12 Jan 2011 Independent Cueing/Safety Concerns Some Assist Required Total Assistance

S Comments: Compiled by: C T Cognitive Status: I A S A � OT � RN R � PT � SLP Orientation � � � � � SW � Other Motivation/initiation � � � � (Please Initial) Judgment � � � � Safety judgment � � � � Problem solving � � � � Memory (short term) � � � � Memory (long term) � � � � Attention � � � � Follow instructions � � � � Frustration tolerance � � � � Insight � � � � Identified risk(s): Perception � � � �

Section 7: Swallowing/Diet Information

1. Diet Texture:

2. Has a swallowing assessment ever been completed? � No �Yes

If yes, please indicate when the swallowing assessment was completed.

Section 8: Communication Information Please indicate current level of communication at time of referral.

1. Method of Expression � Verbal �Sign Language/Functional Gestures � Writes Message/Communication Book �Assistive Device (Specify Details) � No Means of Relaying Messages

CR 009B 13 Jan 2011 2. Speech a. Clarity � Good �Fair � Poor �Very Poor � No Speech

b. Naturalness � Good �Fair � Poor �Very Poor � No Speech

3. Communication Competency (i.e. ability to understand and get messages across)

a. Comprehension � Good �Fair � Poor �Very Poor � No Speech

b. Expression � Good �Fair � Poor �Very Poor � No Speech

Section 9: Applicant Questions The following questions are intended to be completed by the applicant. If necessary, a care provider can provide guidance in answering these questions. Please indicate that assistance was provided.

1. Since your injury, have you noticed a difference in your ability to remember things? Can you give some examples?

CR 009B 14 Jan 2011 2. Please describe a typical day and explain what you do from the time you get up until the time you go to bed.

3. Please describe 3 skills that you would like to improve upon and why you feel these skills are important.

4. Please describe your interests and hobbies.

5. Was assistance provided to applicant while answering these questions? � No �Yes

If yes, please indicate by whom.

Name of Referring Source/Designation

______Signature of Referring Source Date

CR 009B 15 Jan 2011 Section 10: Documentation Checklist Please ensure the following documents are included with this referral form.

� Admission and Discharge Reports from all Admissions

�Medication List

� History and Physical Examination

�Consultative Reports

� Laboratory and Diagnostic Imaging Reports (most importantly CT Scans and MRIs of the head)

� Operative Reports

�Reports from all Disciplines (as available)

� Neuropsychology

�Psychology

� Speech Language Pathology

�Occupational Therapy

� Physical Therapy

�Audiology

� Mental Health

�Social Work History

�Recreation Therapy

Please forward referral and other documentation by mail. Upon receipt of this referral package, the SMHC ABI Program Intake team will review the package and determine eligibility for the transitional residence. You will then be contacted for a follow up appointment with the occupational therapist at the transitional residence, or you will receive notification that you are not an eligible candidate for the transitional residence at this time. You may be referred to another ABI program/service if deemed appropriate.

Please complete and forward by mail (DO NOT FAX) to the address below.

Program Manager ABI Program Selkirk Mental Health Centre Box 9600

CR 009B 16 Jan 2011 SELKIRK MB R1A 2B5

CR 009B 17 Jan 2011