Infirmary Program Referral Form

Infirmary Program Referral Form

Date: ______Date Received: ______

(completed by Infirmary Staff)

INFIRMARY PROGRAM REFERRAL FORM[1]

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: ______

¨ 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: ______

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

¨ 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 / □Yes / □No
Client has participated in developing of the goals for a short term stay in the Infirmary. / □Yes / □No
Client has given verbal and/or written consent / □Yes / □No
Referee Signature / Date

[1] Revised April 2015