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Bilingual Hospital 2 Home Referral Form

Bilingual Hospital 2 Home Referral Form

The estimated Discharge date is preferred two weeks from when the referral is received*
Eligibility Criteria
Please tick in the Boxes:
Section 1: Personal Details
Identify as:
Interpreter Required

Family and Domestic Violence history?

** - required

Does the person have an existing Mental Health Care Plan?

** - required
Section 2: Referrer's Details
Section 3: Reasons for Referral
Level of risk:

(please select the most appropriate)

Suicide
Self-Harm
Aggression
Vulnerability
Please advise on any substances used:

(please select the most appropriate)

Alcohol
Illicit drugs
Would you like assistance in abstaining from use?
Are you currently receiving support to assist in abstaining?
Existing Support Network:
Linkage of supports
Please tick all that apply
Section 4: Secondary Contact Details
Section 5: Hospital Details (If Applicable)
Legal Status on Admission
Discharge Plan attached to this referral?

By submitting this application, I (being referred) give consent for One Door Mental Health to communicate and collect information from the referrer. I give consent for One Door Mental Health to keep a record of my referral which will remain strictly confidential and only used for its intended purpose.


 

Mandatory field(s) marked with *