Canadian Mental Health | Kenora Branch Referral Form
  1. Referral To



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  2. Client Name:
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  3. Street Number:
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  4. Street:
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  5. Apt Number:
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  6. Town or City:
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  7. Province:
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  8. Postal Code:
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  9. Home Number:
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  10. Health Card Number:
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  11. Work Number:
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  12. Date Of Birth:
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  13. Sex:
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  14. Gender:
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  15. Pronoun (he/she/they):
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  16. If applicable, preferred name:
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  17. Preferred Language:
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  18. Mental Health Diagnosis (DSM):
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  19. Family or Significant Other:
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  20. Family or Significant (Other Home Phone)
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  21. Family or Significant (Other Work Phone)
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  22. Has this referral been discussed with the Client
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  23. Has this referral been discussed with the Family or Significant Other:
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  24. Has the Client reviewed Safety Educational Materials including "Its safe to ask" and "Your Healthcare - Be involved" available online at www.safetoask.ca or at the CMHA Kenora Office
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  25. Substitute Decision Maker and Relationship (if applicable)
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  26. Psychiatrist or Psychologist Name:
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  27. Psychiatrist or Psychologist Phone Number:
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  28. Family Doctor Name:
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  29. Family Doctor Phone Number:
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  30. Has the Client Completed a Release of Information
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  31. Current Medications including dosages
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  32. Current Medical or Physical or Cognitive Health Concerns:
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  33. Substance Use (drugs, alcohol, severity):
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  34. Indicate all that apply






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  35. Recent Psychiatric Hospitalizations:
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  36. List Contacts with Criminal Justice System (e.g. charges, probation, jail):
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  37. Indicate serious difficulty/history with any of the following:















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  38. Indicate involvement with any of the following:










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  39. Please describe involvement:
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  40. Please Explain Briefly Why Current Follow-up is Inadequate:
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  41. Referral Source
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  42. Referral Source Position
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  43. Date:

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  44. E-mail
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  45. Prove you're Human(*)
    Prove you're Human
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  46. Submit