Get Download Referral Form Here Pdf - Trillium Health Partners

Completing the Download Referral Form Here Pdf for Trillium Health Partners is an essential step in referring a client for Tele-Mental Health services. This guide provides clear and supportive instructions to help you fill out the form accurately and effectively.

Follow the steps to successfully complete the referral form.

1. Click ‘Get Form’ button to access the referral form and open it in your preferred editor.
2. Enter the date of the referral in the format DD/MM/YYYY. This helps the agency record when the referral was made.
3. Fill in the client's name, including their surname and first name, ensuring accurate spelling.
4. Provide the complete address of the client, including street number, name, apartment number (if applicable), city, and postal code.
5. Record the client's phone numbers, including home and an alternate number for contact purposes.
6. Indicate the health card number, separating it accurately as required.
7. Select the preferred language of the client: English, French, or Other, and specify if it's Other.
8. Input the client's date of birth in the format DD/MM/YYYY.
9. Determine if a translator is required by checking Yes or No.
10. Record the psychiatric diagnosis or presenting problem, and provide a clear reason for the referral.
11. Detail any relevant medical history and current medications the client is taking.
12. Complete the risk assessment section. Assess and answer questions regarding immediate risks and substance use, followed by your signature to confirm the assessment.
13. Indicate permission to leave a message and provide the preferred contact method.
14. Fill in the contacts for further information, including the current psychiatrist and family physician's details.
15. Complete the referring agency and individual details, including signature and contact phone number.
16. Once all sections are completed, save your changes, and prepare to download, print, or share the form as required, ensuring to fax it to the specified number.

Complete the referral form online today to support the mental health needs of those in your care.