Alberta Psychiatry Consultation Referral Form

Alberta Psychiatry Consultation Referral Form
Date*

MonthDayYear
Date
REFERRAL SOURCE
Referrer Name*

First NameLast Name
Billing No #
CPSO No #
Type*

Family PhysicianNurse PractitionerPsychiatristOther Physician
Are you the patient's GP?*

YesNo
If NO, please provide the patient's GP details so the report can be sent to them. GP Name:
Clinic Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Phone*
Please enter a valid phone number.
Fax*
Please enter a valid phone number.
Email*
example@example.com
How did you find our clinic?
CONSENT
I understand that this referral is for single consults and I agree to manage the follow-up care for the client?*

Yes
Is the client aware of and in agreement with this request for service?*

Yes
Does the client consent to the sharing of this referral with other health care providers?*

Yes
CLIENT INFORMATION
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Allergies
Provincial Health Card Number #*
Preferred Contact #*
Can messages be left at this number?

YesNo
Alternate Contact #
Can messages be left at this number?

YesNo
Email Address*
example@example.com
Can messages be left at this email?

YesNo
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
What languages can the patient communicate in?
Does the patient have coverage for Psychotherapy?
Is the patient currently receiving Psychotherapy?

YesNo
Payment
Employment Status
Legal Involvement?

YesNo
If yes, please describe
REASON FOR THE REFERRAL
Psychiatric DiagnosisTreatment Review and RecommendationsSecond Opinion
Patient Presenting History:
Does the patient have any of the following? (select all that apply)*

AddictionsAttention ProblemsEating ProblemsLife Transition/ChangePhobiasRelationship IssuesSkin picking and or Hair pullingWorkplace stressAnger ProblemsCommunication ProblemsGriefObsessions / CompulsionsPhysical Health ProblemsSelf-harmSleep ProblemsAnxietyDepressionHoardingPanicPost-Traumatic StressSuicide AttemptsSocial Anxiety
Please provide any relevant information regarding the patient's situation regarding the previously ticked problem areas.
Has the client had any previous psychiatry assessments? If YES, please include these with the referral.*
Has the patient had previous psychological assessments?*
Has the client had any previous mental health treatment? If YES, please provide details.
Current and Known Past Medications:
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Date*

MonthDayYear
Date
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Alberta Psychiatry Consultation Referral Form

REFERRAL SOURCE

CONSENT

CLIENT INFORMATION

REASON FOR THE REFERRAL