Referral Form

Referral To(*)

Assertive Community Treatment Team (ACTT)

Kenora Supportive Housing Program

Forensic Case Management

Counselling & Treatment

Mental Health & Justice Rent Supplements

Mental Health & Addictions Rent Supplements

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Client Legal Name:(*)

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If Applicable, Preferred Name(*)

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Current Address (Full)(*)

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Home Address (Full)(*)

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Phone Number:(*)

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Work Number:(*)

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Health Card Number:(*)

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Date Of Birth:(*)

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Sex Assigned at Birth(*)

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Gender Identity(*)

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Pronoun (he/she/they):(*)

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Preferred Language:(*)

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Mental Health Diagnosis (DSM):(*)

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Family or Significant Other:(*)

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Family or Significant (Other Home Phone)(*)

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Family or Significant (Other Work Phone)(*)

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Has this referral been discussed with the Client(*)

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Has this referral been discussed with the Family or Significant Other:(*)

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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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Substitute Decision Maker and Relationship (if applicable)(*)

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Psychiatrist or Psychologist Name:(*)

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Psychiatrist or Psychologist Phone Number:(*)

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Family Doctor Name:(*)

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Family Doctor Phone Number:(*)

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Has the Client Completed a Release of Information(*)

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Download our Release of Information Document here, Fill it out and upload prior to submitting.

Upload your Release of Information

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Current Medications including dosages(*)

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Current Medical or Physical or Cognitive Health Concerns:(*)

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Substance Use (drugs, alcohol, severity):(*)

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Indicate all that apply(*)

60 or more days in hospital OR 5 or more ER visits OR 3 or more hospitalizations in the last year

High risk of or recent history of criminal justice involvement

Coexisting substance abuse disorder

Severe or intractable major symptoms

Would require institutional placement without intensive

outpatient services

Otherwise unable to participate in office-based services

None N/A

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Recent Psychiatric Hospitalizations:(*)

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Include the name of the Hospitals, Date of Admissions, Date of Discharge and reason for Hospitalization. Please specify if N/A

List Contacts with Criminal Justice System (e.g. charges, probation, jail):(*)

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Indicate serious difficulty/history with any of the following:(*)

Indicate involvement with any of the following:(*)

Please Explain Briefly Why Current Follow-up is Inadequate:(*)

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Date:(*)

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Referral Source(*)

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Referral Source Position(*)

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E-mail(*)

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If referring to Rent Supplement Programs Please Complete:

Will the Applicant agree to participate in Intensive Case Management Services?

YesNo Invalid Input

If No Explain:

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What is the best way for way for the Housing Coordinator to contact the applicant?

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Does the applicant currently receive Case Management Services?

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If yes to the above question, with whom?

CMHAK/ACTTOther Agency Invalid Input

Name of Case Manager:

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Agency:

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Source of Income:

Case Worker name and contact (if applicable):

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Housing Preferences: Services Nearby:

Do you require a unit where pets are permitted?

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Is there anywhere you cannot legally reside (due to conditions or probation)

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Specific Concerns:

Has applicant ever lived in rent supplemented housing?

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Are there any arrears owing?

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If Yes list amount:

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reCAPTCHA(*)

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Submit

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