CDE ID This instrument was downloaded from the CAMH Common Data Elements Library. All fields have been institutionally standardized and should not be modified. Please direct any questions or concerns to clinical.redcap@camh.ca If you have any questions about the referral process, please call
CAMH Referral Form INFORMATION FOR REFERRING PROVIDERS:
A physician or nurse practitioner referral is required for the majority of services at CAMH A physician referral is preferred for the following services: Geriatric Mental Health Services (incl. Memory Clinic) Complex Care and Recovery (incl. Downtown ICM/ACTT, Metabolism Clinic, Medication Assessment & Psychology Psychosis Services) For Addiction Services, patients may self-refer by calling Access CAMH at 416 535-8501, press 2, then press 4. If the patient already has a methadone/ suboxone provider or an addictions physician, involved in their care, that provider will need to fax the completed CAMH referral form. It is preferred that the referral comes from the treating psychiatrist or physician. Individuals requiring psycholegal assessments who are referred by the court, legal counsel or other third parties should be referred to the psycholegal clinic. Note there is an alternate referral process for this clinic - details can be found at www.camh.ca INFORMATION FOR YOUR PATIENT:
Please ensure your patient is aware that the referral is being made. Access CAMH will make two attempts to contact the patient and leave two voicemails, when consent is provided. If the patient cannot be reached, the referring provider will be notified. Note the number will appear as a blocked caller ID. Please encourage your patients to call Access CAMH to check on the status of their referral Given CAMH is an academic research hospital your patient may be invited to participate in research opportunities at CAMH. They do not need to accept. Given CAMH is a teaching hospital, your patient can expect to have residents or students involved in their care. HOW TO SUBMIT A REFERRAL:
Please complete the following form. All fields should be filled. Alternatively, you may download and complete the fillable PDF , faxing the form to 416-979-6815 If your patient is in need of immediate help, please direct them to the nearest emergency department or call 911
Date of Referral Today D-M-Y Legal First Name:* must provide value
Legal Last Name:* must provide value
Preferred Name: (If applicable)
Date of Birth:* must provide value
D-M-Y Age View equation
DOB must be BEFORE date of referral
Gender* must provide value
Female Male Trans Woman Trans Man Two-Spirit Genderqueer Gender fluid Androgynous Non-binary Other
Specify other gender* must provide value
(If applicable)
Health Card #:* must provide value
Enter number without dashes or spaces
Health Card Version Code:* must provide value
Health Card Expiration Date:* must provide value
D-M-Y If the patient does not have a Health Card, please provide their Mother's Maiden Name:* must provide value
Patient address:* must provide value
Unit number: Patient city:* must provide value
Patient province:* must provide value
Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Patient postal code:* must provide value
Is there a need for an interpreter?* must provide value
Yes
No
Please specify which language:* must provide value
Are there any accessibility concerns?* must provide value
Yes
No
Please specify:* must provide value
By listing telephone numbers or an email address below, the referral source confirms that the patient consents for CAMH to call/ email them regarding this referral. CAMH will refrain from communicating unrequired personal information until consents are verified.
Patient/ Delegate Telephone Number(s)/ E-mail Address (Specify type: home, office, cell, etc.)
Contact information below is for:* must provide value
Patient
Delegate
Please specify relationship to patient:* must provide value
Type* must provide value
e.g., home, office, cell, etc.
Tel #1:* must provide value
(###) ###-####
Consent to voicemail messages:* must provide value
Yes
No
Check to enter secondary phone number
Type e.g., home, office, cell, etc.
Tel #2: (###) ###-####
Consent to voicemail messages: Yes
No
Email address Contact preference(select all that apply)
* must provide value
Phone
Text
Email
Custody Status:* must provide value
Joint Custody
Sole Custody
Lives with both parents/ Married/ Common Law
Other (e.g., CAS)
Please specify* must provide value
Guardian 1 Name:* must provide value
Guardian 1 Telephone:* must provide value
(###) ###-####
Guardian 2 Name:* must provide value
Guardian 2 Telephone:* must provide value
(###) ###-####
Provider First Name* must provide value
Provider Last Name* must provide value
Billing Number:* must provide value
Please select one of the following:* must provide value
Family Physician
Nurse Practitioner
Methadone/ Suboxone Provider
Psychiatrist
Other
Please specify other provider:* must provide value
Provider address:* must provide value
Unit number: Provider city:* must provide value
Provider province:* must provide value
Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Provider postal code:* must provide value
Provider Telephone: * must provide value
(###) ###-####
Provider Fax:* must provide value
(###) ###-####
Provider Email:* must provide value
Does your patient currently have a psychiatrist?* must provide value
Yes
No
Unknown
Psychiatrist First Name:* must provide value
Psychiatrist Last Name:* must provide value
Is the patient's current psychiatrist aware of the referral?* must provide value
Yes
No
Please indicate why not* must provide value
**If the patient has a psychiatrist it is preferred the referral comes from them.**
Consultation notes upload: ( MB)
Please indicate the primary reason for referral (specify current symptoms, presenting problems and history) * must provide value
**Individuals requiring psycholegal assessments who are referred by the court, legal counsel or other third parties should be referred to the psycholegal clinic. Note there is an alternate referral process for this clinic
Please select the service you're seeking for your patient* must provide value
Diagnostic Clarification
Medication Review
Treatment Recommendations
Specific Treatment (e.g., CBT, rTMS, ECT)
All of the above
Other
Specify Specific Treatment* must provide value
Specify other service* must provide value
The option "
Have you completed any of the following assessments with the patient?(Check all that apply)
* must provide value
PHQ9
GAD7
None of the above
These assessments are mandatory for specific treatment such as CBT. It is strongly encouraged you complete these with your patient before referral PHQ9 Score* must provide value
GAD7 Score* must provide value
Is there any active substance use to report?
* must provide value
Yes
No
* must provide value
Frequency (e.g., daily, weekly, etc.)
* must provide value
Frequency (e.g., daily, weekly, etc.)
Frequency (e.g., daily, weekly, etc.)
Frequency (e.g., daily, weekly, etc.)
Frequency (e.g., daily, weekly, etc.)
This information is used to optimally plan for the patient's first appointment and to ensure their safety and the safety of our staff. **If any of the above risks and safety concerns are selected, you are REQUIRED to provide additional details**
Suicide Attempt/ Ideation* must provide value
Yes
No
Date of Suicide Attempt/ Ideation* must provide value
Today D-M-Y Details of Suicide Attempt/ Ideation* must provide value
Deliberate Self-harm* must provide value
Yes
No
Date of Deliberate Self-harm* must provide value
Today D-M-Y Details of Deliberate Self-harm* must provide value
Violent Behaviour/ Safety Concerns* must provide value
Yes
No
Date of Violent Behaviour/ Safety Concerns* must provide value
Today D-M-Y Details of Violent Behaviour/ Safety Concerns* must provide value
Legal Involvement* must provide value
Yes
No
Date of Legal Involvement* must provide value
Today D-M-Y Details of Legal Involvement* must provide value
Fire Setting* must provide value
Yes
No
Date of Fire Setting* must provide value
Today D-M-Y Details of Fire Setting* must provide value
Is there any medication information to report?
* must provide value
Yes
No
Medication #1 Name* must provide value
Current?* must provide value
Yes
No
Dose ______ * must provide value
Frequency ______ * must provide value
Response & Adverse Effects of ______ * must provide value
Medication #2 Name Current? Yes
No
Dose ______ Frequency ______ Response & Adverse Effects of ______ Medication #3 Name Current? Yes
No
Dose ______ Frequency ______ Response & Adverse Effects of ______ Medication #4 Name Current? Yes
No
Dose ______ Frequency ______ Response & Adverse Effects of ______ Medication #5 Name Current? Yes
No
Dose ______ Frequency ______ Response & Adverse Effects of ______ Has this patient received any treatment within the community within the past two years?* must provide value
Yes
No
Organization #1* must provide value
Describe Involvement* must provide value
Organization #2 Describe Involvement
Organization #3 Describe Involvement
* must provide value
Additional Documentation
You may upload any additional documentation here
( MB)
Completed by:* must provide value
Signature:* must provide value
( MB)
Chart Tab: Referrals/Intake
PDF email address for Access CAMH* must provide value
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