<p>Infirmary Program Referral Form </p><p>Date: ______Date Received: ______(completed by Infirmary Staff)</p><p>INFIRMARY PROGRAM REFERRAL FORM1</p><p>CLIENT INFORMATION</p><p>Client Name: __ LAST NAME, FIRST NAME __ (Preferred Name) _</p><p>DOB: _____ YYYY/MM/DD ______AGE: ______</p><p>OHIP#:______VC:______Other: ______</p><p>Medication coverage:______</p><p>Gender: □M □F □Transgender □Other:______Preferred Pronoun:______</p><p>Client Contact #:______</p><p>Current living situation: (please check the appropriate box)  Homeless- (Rough)</p><p> Homeless- (Couch surf)</p><p> Homeless- (shelter)</p><p> Housed</p><p> Supportive Housing</p><p>If Housed, Address:______</p><p>SOURCE OF REFERRAL Referee Name:______Title: ______</p><p>Contact:______ext. ______Pager/Cell:______(please check the appropriate box)  Hospital : ______DEPT: ______</p><p> Community Agency: ______</p><p> SHC: Program: ______</p><p>1 Revised April 2015</p><p>1 Infirmary Program Referral Form </p><p> Self </p><p>*Expected Outcome/Change &/or Improvement from short-term stay: </p><p>Primary medical diagnosis: ______</p><p>Other health issues: ______</p><p>Mental health issues: ______</p><p>SUBSTANCE USE  Actively using substance(s)  Currently detoxing  Abstinence  None  History of Use: ______Substance(s) of choice:______Pattern of use:______</p><p>Primary Care provider: ______Contact: ______</p><p>CCAC SUPPORT Does the client require CCAC support in the community? (please circle) Yes No</p><p>If yes,  CCAC referral made Date of referral:______Service start date: ______</p><p>2 Infirmary Program Referral Form </p><p>Coordinator:______Contact:______ext.______Reason for service:  RN, specify service:______ Occupational Therapist  Physiotherapist  Personal Support Worker </p><p>MEDICAL DEVICES  Dressings (specify type): ______)  PICC line  Catheter  Ostomy  Cast  Drains (specify type: ______)  Port-o-cath  Other: ______MOBILITY AIDS  Wheelchair  Scooter  Walker  Cane  Crutches  Other: ______</p><p>SAFETY RISKS  Falls </p><p> Suicidal ideations</p><p> Self harm</p><p> Aggression Verbal/Physical </p><p> Seizures </p><p>3 Infirmary Program Referral Form </p><p> Choking </p><p> Cognitive impairment </p><p> Other: ______</p><p> Behaviours of Concern:______</p><p>______I confirm I have attached:  Current Med List  Relevant consult notes (i.e. medical/surgical/Psych, Social Work, PT/OT, Wound care, etc.)  Relevant Labs, Imaging and screening results (CXR, etc.)  MRSA screening results (if available)  VRE screening results (if available)  Opiate Substitute Therapy (Methadone) Provider information or □N/A  Discharge Summary</p><p> List of follow up appointments (including name of person/service; location; date; time)</p><p>Client is aware of this referral to the Infirmary Program □Y □ es No Client has participated in developing of the goals for a short term stay in the Infirmary. □Y □ es No Client has given verbal and/or written consent □Y □ es No</p><p>Referee Signature Date</p><p>4</p>