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How to Complete the Sunnybrook Youth Psychiatry Outpatient Program External Referral Form

The Sunnybrook Youth Psychiatry Outpatient Program is designed to provide specialized psychiatric care to youth experiencing significant mental health challenges. This guide will help you correctly complete the external referral form, ensuring that the patient receives the appropriate care and support. This form must be filled out by a healthcare provider, such as a family doctor or psychiatrist, who is referring a patient to the program.

Step-by-Step Instructions

1. Patient Demographic Information

  • Physician Referred To: Enter the name of the physician to whom the referral is being made.
  • Referral Date: Fill in the date when the referral is being made (DD/MM/YYYY format).
  • Surname (PRINT): Enter the patient's last name in clear print.
  • Given Name (PRINT): Enter the patient’s first name.
  • Date of Birth: Provide the patient’s date of birth (DD/MM/YYYY format).
  • Age: Indicate the patient’s age.
  • Gender: Check the appropriate box for the patient’s gender (Male, Female, or Other).
  • Patient Phone: Provide the patient’s contact number.
  • Address: Enter the patient's full residential address. If the patient’s address is the same as their parents’, check the “Yes” box; otherwise, check “No.”
  • Health Card #: Enter the patient’s health card number and version code (VC).
  • Children’s Aid Society Involvement: Indicate whether the patient has involvement with the Children’s Aid Society by checking "Yes" or "No."

2. Current Medications

  • List all current medications the patient is taking, including the dosage and duration. You may list up to six medications.

3. Referring Source Information

  • Name (PRINT): Enter the full name of the referring healthcare provider.
  • Address: Provide the referring healthcare provider’s address.
  • Phone: Include the phone number of the referring healthcare provider.
  • Billing Number: Enter the referring healthcare provider’s billing number.
  • Check the appropriate box to indicate whether the referring source is a family doctor, psychiatrist, or other healthcare provider.

4. Parent Demographic Information

  • Name: Provide the name of the parent or guardian.
  • Address: If different from the patient, provide the parent or guardian’s address.
  • Home Phone: Enter the parent or guardian’s home phone number.
  • Cell Phone: Provide the parent or guardian’s cell phone number.
  • Email: Enter the parent or guardian’s email address.

5. Reason for Referral

  • Details Regarding Reason for Referral: Briefly describe the primary reason for the referral. This section should include specific symptoms, behaviors, or concerns that necessitate psychiatric evaluation or treatment.

6. Primary and Secondary Reasons for Referral

  • Primary Reason for Referral: Select one primary reason for the referral by checking the appropriate box (e.g., Psychosis, Depression, Hypo/Mania, Anxiety).
  • Secondary Reason(s): If applicable, check any secondary concerns that are relevant but not the primary reason for referral.

7. Additional Areas of Concern

  • If there are other related concerns, such as alcohol/drug abuse, antisocial behavior, developmental issues, dysfunctional eating, self-destructive behaviors, ADHD, school issues, or other concerns, check the relevant boxes.

8. Past Mental Health Treatment

  • Check the appropriate box to indicate whether the patient has had previous mental health treatment. If so, forward all relevant assessment, treatment, or summary notes with this referral.

9. Family Psychiatric History

  • Indicate whether there is a family history of psychiatric conditions, such as depression, bipolar disorder, anxiety, or substance use. Specify if the relative is a first or second-degree relative.

10. Submission

  • After completing the form, fax it to the Division of Youth Psychiatry Central Intake at 416-480-6818.

Troubleshooting Tips

  • Incomplete Information: Ensure all sections are filled out completely. Missing information may delay the referral process.
  • Incorrect Contact Details: Double-check phone numbers, email addresses, and other contact details to avoid communication issues.
  • Proper Documentation: Attach all necessary documents, such as previous mental health records, to support the referral.

FAQs

What if the patient’s postal code does not begin with 'M'?

  • The patient’s postal code must begin with 'M' to be eligible for this program. If not, consider alternative services.

How soon will we hear back after submitting the referral?

  • The response time may vary; the clinic will contact the referring physician or the patient’s family directly.

Can I submit the form via email instead of fax?

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