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REFERRAL FORM

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REFERRAl FORM
Canadian Mental Health | Kenora Branch Referral Form
  1. Referral To



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  2. Client Name:(*)
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  3. Street Number:(*)
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  4. Street:(*)
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  5. Apt Number:(*)
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  6. Town or City:(*)
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  7. Province:(*)
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  8. Postal Code:(*)
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  9. Home Number:(*)
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  10. Health Card Number:
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  11. Work Number:
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  12. Date Of Birth:(*)
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  13. Sex:(*)
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  14. Gender:(*)
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  15. Pronoun (he/she/they):
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  16. If applicable, preferred name:
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  17. Preferred Language:(*)
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  18. Mental Health Diagnosis (DSM):(*)
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  19. Presenting Issues(*)
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  20. What would you like support with?(*)
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  21. Family or Significant Other:(*)
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  22. Family or Significant (Other Home Phone)
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  23. Family or Significant (Other Work Phone)
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  24. Has this referral been discussed with the Client
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  25. Has this referral been discussed with the Family or Significant Other:
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  26. Has the Client reviewed Safety Educational Materials including "Its safe to ask" and "Your Healthcare - Be involved" available online at www.safetoask.ca or at the CMHA Kenora Office
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  27. Substitute Decision Maker and Relationship (if applicable)
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  28. Psychiatrist or Psychologist Name:(*)
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  29. Psychiatrist or Psychologist Phone Number:(*)
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  30. Family Doctor Name:(*)
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  31. Family Doctor Phone Number:(*)
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  32. Has the Client Completed a Release of Information(*)
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  33. Current Medications including dosages(*)
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  34. Current Medical or Physical or Cognitive Health Concerns:(*)
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  35. Substance Use (drugs, alcohol, severity):(*)
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  36. Indicate all that apply(*)







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  37. Recent Psychiatric Hospitalizations:(*)
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    Please Specify if "None - N/A"
  38. List Contacts with Criminal Justice System (e.g. charges, probation, jail):(*)
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  39. Indicate serious difficulty/history with any of the following:(*)
















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  40. Indicate involvement with any of the following:(*)











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  41. Please describe involvement:(*)
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  42. Please Explain Briefly Why Current Follow-up is Inadequate:(*)
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  43. Date:(*)
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  44. Referral Source(*)
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  45. Referral Source Position(*)
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  46. E-mail(*)
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  47. reCAPTCHA(*)
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  48. Submit

Contact Information

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1 (807) 468-1838
227 Second Street South
Kenora, Ontario
P9N-1G1
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