Infirmary Program Referral Form

Date: ______Date Received: ______(completed by Infirmary Staff)

INFIRMARY PROGRAM REFERRAL FORM1

CLIENT INFORMATION

Client Name: __ LAST NAME, FIRST NAME __ (Preferred Name) _

DOB: _____ YYYY/MM/DD ______AGE: ______

OHIP#:______VC:______Other: ______

Medication coverage:______

Gender: □M □F □Transgender □Other:______Preferred Pronoun:______

Client Contact #:______

Current living situation: (please check the appropriate box)  Homeless- (Rough)

 Homeless- (Couch surf)

 Homeless- (shelter)

 Housed

 Supportive Housing

If Housed, Address:______

SOURCE OF REFERRAL Referee Name:______Title: ______

Contact:______ext. ______Pager/Cell:______(please check the appropriate box)  Hospital : ______DEPT: ______

 Community Agency: ______

 SHC: Program: ______

1 Revised April 2015

1 Infirmary Program Referral Form

 Self

*Expected Outcome/Change &/or Improvement from short-term stay:

Primary medical diagnosis: ______

Other health issues: ______

Mental health issues: ______

SUBSTANCE USE  Actively using substance(s)  Currently detoxing  Abstinence  None  History of Use: ______Substance(s) of choice:______Pattern of use:______

Primary Care provider: ______Contact: ______

CCAC SUPPORT Does the client require CCAC support in the community? (please circle) Yes No

If yes,  CCAC referral made Date of referral:______Service start date: ______

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Coordinator:______Contact:______ext.______Reason for service:  RN, specify service:______ Occupational Therapist  Physiotherapist  Personal Support Worker

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: ______

SAFETY RISKS  Falls

 Suicidal ideations

 Self harm

 Aggression Verbal/Physical

 Seizures

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 Choking

 Cognitive impairment

 Other: ______

 Behaviours of Concern:______

______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

 List of follow up appointments (including name of person/service; location; date; time)

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

Referee Signature Date

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