CAMH REFERRAL - INFORMATION AND INSTRUCTIONS
If you have any questions about the referral process, please call Access CAMH at 416-535-8501, press 2.
A physician referral is required for the majority of services at CAMH.
A physician referral is preferred for the following services:
• Geriatric Mental Health Service (including Memory Clinic)
• Schizophrenia Service (STARS)
Please FAX completed CAMH Referral form to: 416-979-6815
*For Telepsychiatry, please fax the form to: 416-260-4186
*For Sexual Behaviour Clinic only, please fax the form to: 416-260-4187
Those seeking addiction and/or substance use assessment and treatment can self-refer by calling Access CAMH
(416-535-8501, press 2).
QUALITY CARE
In order to help us provide the best care, please include the following (if possible):
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Relevant lab and test results (e.g., therapeutic drug levels)
Medication sheet
Previous psychiatric consultations or discharge summaries
Medical reports
Physical findings
Psychological reports
Please include a signed Consent for Disclosure of Personal Health Information form, if necessary.
If your client is in need of immediate help, please direct them to the nearest emergency department or call 911.
Please note: At CAMH, we integrate clinical care and research to improve the prevention, diagnosis, and treatment of
mental health and addiction issues. Clients/patients are key to this goal and may be invited to participate in research.
Instruction page - CAMH Referral
F0102-20160519
This page not to be filed on CAMH client/patient health record
Client/Patient ID Label
CAMH REFERRAL FORM
(For CAMH use only)
Date of referral (dd/mm/yyyy):
CLIENT/PATIENT INFORMATION
Legal name:
REFERRAL SOURCE INFORMATION
Name:
(last name, first name)
(last name, first name)
Check one:
Family Physician
Preferred name (if applicable):
Mother's maiden name:
Tel:
Date of birth:
Fax:
(dd/mm/yyyy)
Nurse Practitioner
Psychiatrist
Other:
E-mail address:
For persons 16 years and older, consent is required for assessment to be Address:
completed. Please ensure you have spoken to the person about the referral.
Is your client/patient aware of this referral?
Yes
If no, please explain:
No
Billing number (if referred by physician):
What is your client's/patient's gender? Check ONE only:
Female
Trans - Female to Male
Intersex
Prefer not to answer
Do not know
Is client's/patient's current psychiatrist aware of referral?
Male
Trans - Male to Female
Other (please specify)
Yes
No
Unknown
Does not have psychiatrist
If Yes, name of psychiatrist:
(last name, first name)
CLIENT/PATIENT ETHNICITY INFORMATION
Telephone number(s) (specify home, office, cell, etc.)
Tel:
Which of the following best describes client/patient racial or ethnic group?
Tel:
Check ONE only.
If you are able to advise, please confirm if confidential messages
can be left at the numbers provided above:
Yes
No Details:
Asian - East (e.g., Chinese,
Japanese, Korean)
Asian - South (e.g., Indian,
Pakistani, Sri Lankan)
By listing an e-mail, the referral source confirms that the client consents
for CAMH to e-mail appointment details and is aware that e-mail is not
entirely secure. CAMH will refrain from sending unrequired personal
information until e-mail addreses and consents are verified.
Asian - South East (e.g.,
Malaysian, Filipino, Vietnamese)
Black - African (e.g., Ghanaian,
Kenyan, Somali)
E-mail address:
Black - North American (e.g.,
Canadian, American)
Address:
Black - Caribbean (e.g.,
Barbadian, Jamaican
Health card #:
First Nations - Non-status
Version code:
Expiry date:
First Nations - Status
Indian - Caribbean (e.g.,
Guyanese with origins in India)
Indigenous / Aboriginal not
included elsewhere
(dd/mm/yyyy)
Is there a need for an interpreter (e.g., for sign language or other language)?
Yes
No
If Yes, please specify:
Inuit
Latin American (e.g., Argentinean,
Chilean, Salvadorian)
Métis
Middle Eastern (e.g., Egyptian,
Iranian, Lebanese)
White - European (e.g., English,
Italian, Portuguese, Russian)
White - North American (e.g.,
Canadian, American)
Mixed heritage (e.g., BlackAfrican and White-North
American) (Please specify)
Other(s) (Please specify)
Prefer not to answer
Do not know
ALTERNATE CONTACT INFORMATION (CLIENT/PATIENT OR LEGAL GUARDIAN CONSENT MAY BE REQUIRED)
Is there anyone other than the client/patient that we should
Yes
No
contact?
(last name, first name)
Relationship to client/patient:
Tel:
Tel:
GUARDIAN AND CUSTODY STATUS (IF APPLICABLE)
1.
Custody Status: Lives with both parents
Joint Custody (both parents
need to be aware and consenting to the assessment) Sole custody
Client lives independently Other (CAS/relative)
2. Guardian name:
Telephone #:
Clear Form
Guardian name:
Telephone #:
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F0102-20160519
Chart Tab: Referral/Intake
Client/Patient ID Label
(For CAMH use only)
Client/patient name:
1. REASON FOR REFERRAL (e.g., consultation, goals for assessment, treatment)
Why are you referring the patient now? (e.g., current symptoms, presenting problems, history)
2. SUBSTANCE USE (current substances, amount, frequency of use, etc.): Does client/patient want help with this issue?
3. RISK ISSUES
RISK ISSUE
CHECK
IF YES, WHEN?
Suicide attempt / ideation
Yes
No
Deliberate self-harm
Yes
No
Violent behaviour
Yes
No
Legal involvement
Yes
No
Fire Setting
Yes
No
Yes
No
DETAILS
4. MEDICATIONS (psychiatric and non-psychiatric - attach additional information if needed)
MEDICATION
CURRENT
PAST
DOSE / FREQUENCY
RESPONSE & ADVERSE EFFECTS
5. AGENCIES, HOSPITALS OR THERAPIES INVOLVED WITHIN THE PAST TWO YEARS
6. RELEVANT MEDICAL / DEVELOPMENTAL HISTORY (e.g., disabilities, intellectual delay, autism, allergies, endocrine,
neurological, respiratory, cardiac, metabolic or other issues)
Completed by:
(print name and credentials)
Clear Form
Date:
(signature)
When completing electronically, the form
should be printed, signed and faxed to CAMH.
(dd/mm/yy)
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F0102-20160519
Chart Tab: Referral/Intake