June 10, 2023 Referrent Information Type of Referral (required) SelfFamilyPrimary Care PractitionerThird Party / Agency Referrent Name Name of Agency Phone Number Referrent Name Phone Number Referrent Name Relationship to Referred Individual Phone Number Referred Individual Legal First Name (required) Legal Last Name (required) Middle Name Preferred Name (goes by) Date of Birth (required) Street Address No fixed address PO Box Town/Township Postal Code Indicate Contact Information and Check Off Preferred Method(s) At least one method required Can message be left? School Name: at school only (for youth self-referral YesNo Cell Phone: CallText YesNo Work Phone: CallText YesNo Home Phone: Call YesNo Email: Use Email Can we send mail correspondence to you home address? (required)YesNo Preferred Language: (required)EnglishFrenchOther Accommodation Needs: ReadingWritingMobilityOther Name of school/daycare (if applicable): Grade: Legal guardian if child under 12*: Contact number: Legal guardian if child under 12*: Contact number: *may be required to provide verification of legal guardianship at intake Primary Care Provider (Family Doctor or Nurse Practitioner): None Phone & Extension: Fax: Are child protection services involved? YesNo Name of agency: Crown wardship or kinship agreement? YesNo Comments: Has individual received services at NOSP previously? (required)YesNo What name did individual previously go by? Presenting Issues (required) Anger issuesAnxietyCaregiver burden/stressCoping challengesEnergy level changesFeelings of hopelessness / worthlessnessFinancial insecurityFood insecurityGender orientationGrief/lossHallucinationsHomeless/risk of homelessnessIntrusive repetitive thoughtsLoneliness / isolationLoss of interestMemory difficultiesParanoid thoughts / delusionsParenting challengesPhysical health concernsPregnancy – currentPregnancy – recent lossProblem gamblingRacing thoughtsRelationship problemsRisk of family breakdownSadness/depressed moodSchool/work difficultiesSelf harm behaviorSeparation/divorceSexualitySleep pattern changesStress levels heightenedSubstance misuseSuicidal ideation – chronicTraumaWorries excessively/panicsOther Other Presenting Issues: Reason for Referral (required) Additional information attached: Risk Factors / Safety Concerns (required) Current self harm behavior(s)Current suicidal ideation (not at imminent risk)Current risk of harm to othersInterpersonal violencePast history of self harm behavior(s)Past history of suicidal ideation and/or actionPast history of causing harm to othersOtherNot Applicable Other Risk Factors: Service(s) Requested (required) Children's Services (0-17 years) or Parent / Guardian SupportAdult Services (18 years +) At least one selection is required: Mental health counsellingSubstance use assessment and counsellingDevelopmental services access / assessmentRural psychology/psychiatryCase management/service coordinationParenting support and targeted interventionTargeted prevention, education and skills support At least one selection is required: Mental health counsellingSubstance use assessment and counsellingProblem gambling assessment and counsellingMental health case managementHousing case managementHousing case management with rental supplementSupport and visiting for seniors, adults with physical disabilities and caregivers – Enrichment and Social Engagement (EASE)OtherPsychiatry consultation (referrals can only be made by a Primary Care Practitioner) Other Service Required: If individual referred for housing supports, risk factor(s): HomelessCouch surfingUnsafe housingRisk of losing housing For individuals referred for rental supplement and housing supports, state current income: Ontario WorksODSPNo incomeOther If individual referred for EASE has Power of Attorney for Personal Care** POA Legal last name: POA Legal first name: Preferred contact information for POA: **may be required to provide verification of POA at intake If Psychiatry Referral By checking this box, I certify that I am the Primary Care Practitioner for the referrent described in this form Attach current medication list: Do you wish to upload any additional attachments (e.g. consents, power-of-attorney information, etc.)?Yes Do you wish to an email notification of your referral submission?YesEnter your email address: Print this form NOTE: Form fields will be reset after submission. If you wish to print this form, please do so before submitting or all content will be lost. Δ
