Soldiers’ Memorial Hospital
462 Main Street
Middleton, NS, B0S 1P0
Phone: (902) 825-4825
Fax:
(902) 825-5181
AVH Chipman
15 Chipman Drive
Kentville, NS B4N 3V7
Phone: (902) 679-2873
Fax: (902) 679-1766
Child and Youth Mental Health Program
REFERRAL FORM
All sections must be completed on both sides. Incomplete or illegible referrals will delay response.
Referred by
(name/relationship):__________________________________
Date of Referral:
Family Physician:
Agency (specify): ___________________________________
□ Client / guardian is aware of and consents to this referral
Name of Client:
DOB: (m/d/y)
Previous Name(s):
For Office use only
HCN#
Expiry Date:
Unit #.
Gender:
Contact Address: (Mailing & Civic)
Ph: (H)
(W)
(Cell)
(Other)
OK to leave messages? □ No □ Yes
Email:
________________________________________
Which number/Special instructions:
______________________
Name of Parent(s) or Legal Guardian:
Parent's Marital Status:
arried/Common/Law
owed
Person(s) child resides with:
ingle
ivorced/Separated
□ Shared care – Specify: ______________________________
□ Primary care provider: ____________________________
Siblings in home (names/ages):
Siblings (names/ages)/parents not in home:
School:
Have you explored private service options (e.g., EAP)?
Yes □
No □ Yes, but not an option □
Grade:
Expectation of Treatment: □ Assessment/Diagnostic clarification □ Therapy/counselling/intervention
□ other (describe)
Current Symptoms:
Are the following affected by symptoms? □ Sleep
□ Appetite
□ Social engagement
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□ Concentration
□ Mood
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Suicide Risk/Self Harm (explain)
Situational Stressors:
□ Separation
□ Legal problems
□ Change of residence
□ Drug or alcohol abuse
□ Other (please specify)
□ Divorce
□ Illness of family member
□ Change of school
□ Financial Stress
□ Increase in family conflict
□ Death of family member
□ Loss/change of job
□ Addition to household (e.g., grandparent, birth of child)
History of counselling services / past psychiatric treatment:
Previous Mental Health Diagnoses:
Other agencies involved:
□ Addictions Services □ Justice □ Probation □ Chrysalis House □ Child Protection □ Income Assistance
□ Public Health □ Healthy Beginnings □ Early Intervention □ Dietician
□ Speech Language Pathology □ Occupational Therapy □ Physiotherapy □ Audiology
□ IWK – Department: __________________________________________________________________
□ Private Practitioner (name) _____________________________________________________________
□ Other_______________________________________________________________________________
Significant Medical Problems:
List ALL Medications (prescription, over-the-counter, herbal), dosages and recent changes:
Please indicate if any of the following are present in any family member of your child (e.g., biological parents,
grandparents, siblings, cousins, aunts/uncles, etc.):
□
□
□
□
Learning disability
ADHD/ADD
Depression
Tic Disorder
□ Mentally challenged
□ Seizures
□ Anxiety
□ Other (please specify):
□ Autism Spectrum Disorder
□ Suicide
□ Alcohol & drug dependency
Preferred Clinic:
□ Kentville/Chipman
□ Middleton/Soldiers’ Memorial Hospital
□ Annapolis Community Health Centre
*If you prefer to be seen in Windsor, a referral to Hants County Mental Health is required (902-792-2042).
*If you prefer to be seen in Digby, a referral to Digby County Mental Health is required (902-245-4709).
Incomplete or illegible referrals will not be processed but will be returned to referral source for completion.
Referral Completed By: _______________________________________________
Revised June 2012
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