Seniors Mental Health Program Referral Note – Fax referral to appropriate service area as indicated on the back of the referral. Client First Name Client Last Name Date of Birth (yyyy-Mon-dd) Gender ☐ Female ☐ Male Personal Healthcare Number Address Postal Code

Referral Date (yyyy-Mon-dd) Referred by

Client Location Phone Number Fax Number ☐ Home ☐ Acute Care Hosp ☐ Seniors Lodge ☐ Continuing Care ☐ Other (specify) ______Name of Physician Is Physician aware of this Phone Number Fax Number referral? ☐ Yes ☐ No Reason for Referral (presenting problems)

Please send a current medication profile with this referral. Expected Outcomes The following lab work results are REQUIRED prior ☐ Assessment by Seniors Outreach Nurse to assessment and current within one month ☐ Behaviour Management Strategies/ Albumin Lipid profile ☐ Nursing Interventions ALP Folate ALT Vitamin B 12 ☐ Consideration for Admission to CCMHBI AST TSH ☐ Medication Review ☐ Bilirubin CBC Other (specify) Calcium Urinalysis ______Creatinine Chest X-ray ______Electrolytes CT Scan Head (if possible) ______Glucose-fasting ECG ______Magnesium Urea

Is the client / guardian aware of this referral and has verbal consent been given ☐ Yes ☐ No Name of Next of Kin Phone Number Alternate Number

Trustee/Power Of Attorney Existing? Name Phone Number ☐ No ☐ Yes ☐ Activated Personal Guardian/Directive: Name Phone Number ☐ No ☐ Yes ☐ Activated

08916(Rev2015-08) Side A Seniors Mental Health Program Referral

Please fax referral to appropriate service area: Service Areas ☐ Drayton Valley Community Phone: (780) 542-3140 ☐ Breton Health Centre Fax: (780) 542-4461 ☐ Lodgepole 4110 - 50 Avenue Drayton Valley, AB T7A 0B3

☐ Wetaskiwin Mental Health Centre Phone: (780) 361-1245 ☐ Millet 5201 - 50 Avenue Fax: (780) 361-1387 ☐ Winfield Wetaskiwin, AB T9A 0S7

☐ Ponoka Ponoka Mental Health Centre Phone: (403) 783-7903 ☐ Maskwacis Box 4244 Fax: (403) 783-7926

NORTH ☐ 233 5110 - 49 Avenue Ponoka, AB T4J 1J1

☐ Rocky Mountain House Health Centre Phone: (403) 844-5235 ☐ Caroline 5016 - 52 Avenue Fax: (403) 844-5236 Rocky Mountain House, AB T4T 1T2

☐ Lacombe Lacombe Mental Health Phone: (403) 782-3413 ☐ Suite 301 Fax: (403) 782-3878 5033 - 52 Street Lacombe, AB T4L2A6 Service Areas ☐ Red Deer Red Deer 49th St. Community Phone: (403) 340-5466 (County of Red Deer and Health Centre – Mental Health Fax: (403) 340-5217 City of Red Deer) 4733 - 49 Street

CENTRAL ☐ Red Deer, AB T4N 1T6 Service Areas ☐ Stettler Stettler Mental Health Centre Phone: (403) 743-2000 ☐ Alix ☐ Consort Stettler Hospital & Care Centre Fax: (403)740-8880 ☐ Erskine ☐ Coronation Bag 500, 5912 - 47 Avenue ☐ Mirror ☐ Delburne Stettler, AB T0C 2L0 ☐ Castor ☐ Donalda

☐ Sylvan Lake Mental Health Services Phone: (403) 887-6777 ☐ Bentley Sylvan Lake Community Health Centre Fax: (403) 887-6721 ☐ 4602 - 49 Avenue ☐ Innisfail Sylvan Lake, AB T4S 1M7 SOUTH ☐ Drumheller Health Centre Phone: (403) 820-7863 ☐ Hanna 351 - 9 Street NW Fax: (403) 820-7865 Drumheller, AB T0J 0Y1 Olds Olds Mental Health Centre Phone: (403) 507-8174 ☐ Alix ☐ Consort 212 5025 - 50 Street Fax: (403) 556-2199 ☐ Bowden ☐ Olds, AB T4H 1R9 ☐ Elnora ☐ Three Hills ☐ Linden ☐ Trochu

08916(Rev2015-08) Side B