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REFERRAL FORM Personal Information Referral Agency: Referent: Client Last Name: Client First Name: Nick Name: Client Gender: F o M o Date of Birth: Age: Language Spoken: Place of Birth: Mother's Maiden Name: Last four digits of S.I.N. : Telephone Number: Health Card Number: First Nation: Status Number: Residing on First Nation: Y o N o Other First Nation Residing On: How Long: Client Full Address: Please include Postal Code Marital Status Living Arrangements Single: o Single Parent: o With Parents: o With Children: Married: o Common-­‐Law: o With Spouse: o With Spouse & Children: o Separated: o Divorced: o With Relatives: o With Friends: o Alone: o Widow/Widower: o Alone: o Other Arrangements: o o Date of Separation/Divorce: Accommodations Following Treatment: Emergency Contact Information Emergency Contact: Relationship of Emergency Contact: Telephone Number: Cellular Number: Family Physician: Telephone Number: BENBOWOPKA TREATMENT CENTER
Revised June 2015 1 CLIENTS FAMILY HISTORY
Who were you raised by? Parents o Grandparents o Extended Family o Foster Parents o Adoptive Family o Who was your primary care giver? ______________________________________________________________ Please describe your parents parenting style: ______________________________________________________ How many siblings do you have? ________________________________________________________________ Did your parents or any other family member attend a residential school? Yes o No o Who? ______________________________________________________________________________________ Client's Dependent Children/Adult Children/Wards Gender Age Name of Guardian During Treatment Is a Children's Aid Society or any other Family Service Agency currently involved with your family? Y o N o Name of Agency: Scheduled Visiting Arrangements: Has C.A.S. or any other Family Service Agency been involved with your family? If so, when: Additional Information List hobbies, interests, strengths, accomplishments or knowledge the client is proud of: BENBOWOPKA TREATMENT CENTRE
Revised June 2015 2 Client Education Elementary Level: Elementary School: Secondary Level: Secondary School: College: Course: Course Completed: Y o N o If no, how many semesters were completed? University: Concentration of Study: Course Completed: Y o N o If no, how many semesters were completed? Trade/Technical Program: Trade School: Course Completed: Y o N o If no, how much of course was completed? Reason for leaving educational institution: Employment Permanent o Full-­‐Time o Part-­‐Time o Seasonal o Temporary o Homemaker o Apprenticeship o Student o Retired o Unemployed o Current Employer: Usual Occupation: Length of Employment: Last Date of Employment: Will you be returning to current place of employment? Employment plans following treatment: Client's Source of Income Employment o Employment Insurance o Ontario Works o Pension o Savings o No Income o Other o ______________________________________________ BENBOWOPKA TREATMENT CENTRE
Revised June 2015 3 MENTAL HEALTH/PSYCHIATRIC HISTORY
In-­‐Patient Name of Facility: Date Admitted: Presenting Problem: Type of Treatment: Duration of Stay: Treatment Completed: Y o N o Has the client ever been hospitalized for mental health issues? Y o N o If yes, please note details: ___________________________________________________ __________________ (Facility Name) (Date) Has the client experienced suicidal ideations or attempted suicide? Y o N o If yes, please note when: ____________________________________________________ Does the client have a history of Psychiatric conditions? Y o N o If yes, provide diagnosis: ____________________________________________ Was a Psychological/Psychiatric Evaluation completed: Y o N o If yes, please include Psychological/Psychiatric Evaluation and a signed consent authorizing the release of the Evaluation to Benbowopka Treatment Centre. PAST MENTAL HEALTH/PSYCHIATRIC In-­‐Patient Name of Facility: Date Admitted: Presenting Problem: Type of Treatment: Duration of Stay: Treatment Completed: Y o N o In-­‐Patient Name of Facility: Date Admitted: Presenting Problem: Type of Treatment: Duration of Stay: Treatment Completed: Y o N o BENBOWOPKA TREATMENT CENTRE
Revised June 2015 4 PREVIOUS ALCOHOL AND SUBSTANCE TREATMENT PROGRAMS ATTENDED (List Most Recent First) Name of Facility: Date Entered: Program Duration: Type of Treatment: Length of Stay: Presenting Problem: Was treatment completed: Y o N o If no, explain reason for leaving the treatment program: _______________________________________________ Duration of abstinence following the treatment program: ______________________________________________ Name of Facility: Date Entered: Program Duration: Type of Treatment: Length of Stay: Presenting Problem: Was treatment completed: Y o N o If no, explain reason for leaving the treatment program: _______________________________________________ Duration of abstinence following the treatment program: ______________________________________________ Additional Information of Past Treatment Programs Attended: Presenting problem(s) for which client now seeks treatment: Identify any issues or concerns client may have regarding treatment at Benbowopka Treatment Centre: BENBOWOPKA TREATMENT CENTRE
Revised June 2015 5 ALCOHOL AND SUBSTANCE USE Identify kind of substance(s) you have used: Please complete all sections Substance Age First Used BENBOWOPKA TREATMENT CENTER
Revised June 2015 Frequency of Use Amount of Used Date Last Used 6 Legal Status Criminal Court System: Pending Charges: Y o N o List Charge(s) _________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Probation/Parole: Y o N o Date __________________________________________________________ Provide a copy of Probation Order Scheduled Court Appearance: Date __________________________________________________________ Family Court System: Are you involved with Ontario Family Court? Y o N o Upcoming Ontario Family Court Date: ____________________________________________________________ ______________________________________________ (Counsellor/Referent Signature) ______________________________________________ (Client Signature) __________________________ (Date) __________________________ (Date) Please inform client he/she cannot enter the treatment program with non-­‐prescribed medication BENBOWOPKA TREATMENT CENTER
Revised June 2015 7 AFTERCARE PLANNING To assist clients in their Aftercare Plan upon completion of the treatment program Client Name: ____________________________________ Referent: _____________________________ Has an Aftercare Plan or Follow-­‐Up Plan been made with the client and you, the Referent? Y o N o Please indicate a date for client's first session with you: ________________________________________ What type of aftercare services will benefit your client: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ What programs are available in your community or organization to assist clients in their recovery? 1.
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Do you feel working together in developing an Aftercare Plan will benefit your client? Y o N o ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Referent Signature: ________________________________ Telephone Number: _______________________________ Date: ______________________________________ BENBOWOPKA TREATMENT CENTRE
Revised June 2015 8 MEDICAL RELEASE INFORMATION CLIENTS RESPONSIBILITIES: Please have all information completed by a Physician/Nurse Practitioner and return the completed form to Benbowopka Treatment Centre. Clients will not receive a treatment date confirmation without a completed Medical PLEASE NOTE: Benbowopka Treatment Centre will not be responsible for any cost with having this Medical Release Information completed. Thank you. Physician/Nurse Practitioner: Please Print Telephone Number: Client Surname: First Name: Date of Birth: Gender: F o M o
Telephone Number: Marital Status: Health Card Number: Client Address: Physical Health and Condition: Please Note Any Future Medical Treatments Client May Require: BENBOWOPKA TREATMENT CENTRE
Revised June 2015 9 Does the client have a disability or mobility condition? Y o N o If yes, please describe: _____________________________________________________________ List Allergies: Special Diet Required? Y o N o Received Influenza Vaccine: Y o N o Received Pneumococcal Vaccine: Y o N o Psychological Condition: PRESCRIBED MEDICATION
Medication PLEASE HAVE MEDICATON BLISTER PACKED Dosage and Directions Physician/Nurse Practitioner Signature: Date: Client Signature: Date: BENBOWOPKA TREATMENT CENTRE
Revised June 2015 Form Reason for Prescribing 10 Accredited Since 2005 CONSENT FOR DISCLOSURE OF PERSONAL AND HEALTH INFORMATION I, _________________________________________________________ , _______________________ (Client Full Name) (Date of Birth) Of: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ (Client’s Full Address) Hereby Authorize: _____________________________________________________________________ (Referent Name) Referring Organization: _________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ o o o o To release this completed Referral Package To provide referral follow-­‐up, Medical and Drug and Alcohol Assessment Forms To release information by means of verbal, facsimile or photocopy; and To assist with treatment planning with the below listed Treatment Centre BENBOWOPKA TREATMENT CENTRE 144 Causley Street, P.O. Box 568 Blind River, ON P0R 1B0 I, hereby authorize the Benbowopka Treatment Centre to share information within my Referral Package with staff whom I may be in contact with as deemed necessary. Client Signature: Date: Referent Signature: Date: BENBOWOPKA TREATMENT CENTRE
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