Sunnybrook Youth Psychiatry Outpatient Referral Form
The Youth Division in the Department of Psychiatry at Sunnybrook Health Sciences Centre is
committed to providing excellent clinical assessments and care for youth. In recent years the time from
referral to assessment has grown substantially, at some points exceeding 5-6 months. Effective June
2012, we have established the following parameters for outpatient assessment referrals.
For youth 14-18 years old residing within Sunnybrook’s catchment area (framed by Bathurst St, the Don
Valley Parkway, Sheppard Ave, and St. Clair Ave), we will continue to accept referrals from physicians
for assessments for youth with complex mood and anxiety disorders.
For youth with the above disorders residing outside our catchment area but within Metro Toronto (416
area code), we will provide assessments provided that they are treatment-refractory (i.e. continue to
experience impairing symptoms despite an adequate course of pharmacological or psychosocial
treatment).
With the exception of bipolar disorder, we are no longer accepting referrals of youth residing outside of
Metro Toronto.
These parameters are necessary for us to maintain our ability to serve our mandates as both a provider of
primary care for youth residing in our catchment area and as a regional resource for treatment-resistant
and tertiary referrals.
I have forwarded all prior assessment/treatment/summary
notes along with this referral to Sunnybrook Youth
Office.
Office Use Only
Referred to: ___________________________________
No previous mental health treatment. (Must reside in
SHSC catchment area.)
Appt. Date: ______/_______/_______
Has not responded to pharmacological treatment
Has not responded to psychosocial treatment
(please indicate medications, dosage, and duration)
(please indicate type and duration of therapy)
___________________________________________
__________________________________________
___________________________________________
___________________________________________
__________________________________________
___________________________________________
Other (explain): __________________________________
___________________________________________
___________________________________________
**Please fax to Denise Hayes @ 416-480-6818**
Physician Referred To: __________________________________ Referral Date: _____/_____/______
DD / MM / YY
Youth Demographic Information
Surname: ______________________________
Given Name: _____________________________
D.O.B: _____/_____/_____ Age: ________
DD / MM / YY
Gender:
Male
Female
Youth Phone: (_____) ______ - _________
Address: __________________________
Same Address as Parents:
Yes
Parental Custody:
No
No
__________________________
Yes
Health Card #: _____________________ VC: _____
Involved in Children’s Aid Society:
Yes
No
Current Medications (please include dosage and duration)
1. _____________________________
2. _____________________________ 3. _____________________________
4. _____________________________
5. _____________________________ 6. _____________________________
Referring Source Information
*Please provide details regarding reason for referral*
Name: _____________________________________
_______________________________________
Address: ________________________________
__________________________________________________
_______________________________
Phone: (_____) ______ - ___________ ext. _______
[ ] Family doctor [ ] Psychiatrist
[ ] Other
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Billing number: _______________________________
__________________________________________________
__________________________________________________
Parent Demographic Information
Name: _____________________________________
________________
Family Psychiatric History
Diagnosis
Address (if different than youth):
______________________________
______________________________
Home Phone: (_____) ______ - ___________
Cell Phone: (_____) ______ - ___________
Depression
Bipolar
Anxiety
Substance Use
Other:
_________________________
1st
Degree
Relative
2nd
Degree
Relative
Reason for Referral
Primary reason:
(select ONE)
Secondary reason(s):
(if relevant)
Psychosis:
Delusions (fixed false beliefs), hallucination
Grossly disorganized/bizarre speech or behaviour
Depression:
Persisting low/sad or irritable mood and
lack of interest, guilt, suicidality, sleep/appetite changes
Hypo/Mania:
Elevated/euphoric or irritable mood with increased
activity/energy/speech/ideas,disinhibited reckless or risky
behavior, grandiosity, and/or decreased need for sleep.
Anxiety
(please specify):
Obsessive thoughts; rituals or compulsions
Post-traumatic stress (anxiety following traumatic event including flashbacks, re-experiencing,
numbness/detachment)
Specific or social phobia, panic attacks, or generalized
Please check additional areas of concern, if relevant - the following disorders/issues should not be a
primary reason for referral to our clinic, but might be comorbid/related concerns:
Alcohol/Drug Abuse
Antisocial Behavior – theft, assault, truancy, fire-setting, lying
Developmental Issues – developmental delay/ mental retardation, autism spectrum symptoms (deficits
in [or idiosyncratic/odd] speech, communication, reciprocity, mannerisms, social skills deficits,
particularly with regard to reading non-verbal cues)
Dysfunctional Eating – excessive dieting, starvation, compulsive exercising, bingeing and purging
Self-Destructive Behaviors – self-injury (e.g. cutting), impulsivity, intense and unstable interpersonal
relationships, prominent anger
ADHD – inattention/hyperactivity or lifelong disorganization attributable to lack of focus
School Issues – learning disabilities, poor grades, poor attendance, behavioral issues, social issues (e.g.
bullying)
Other – (e.g. anger management issues) please elaborate in ‘comments’ section
**Please fax to Denise Hayes @ 416-480-6818**