Referral Type:
Create a New Referral New Referral

Instructions: 

Please send the completed pre-screening form and/or any questions about the program to the program manager: Tera Pollock at tpollock@cmhahpe.ca .  When submitting the form please include signed consent allowing Back to Home Program to contact the referral agency and for release of personal health information. 

Pre-screening will be reviewed within 5 - 7 business days. If approved, the manager will contact you to arrange for step 2 of the formal application process. 
Submit the form. I'm done. Submit
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Referral:
Back to Home Program Referral Form ID
Date: 2025-05-09 16:52
Status: Draft
Attachment(s):
( Max File Size is 256 MB )
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Hide/ShowReferral Requirements:

Referral Requirements: 

For a client referral to be considered, the following conditions must be met:

  • Primary diagnosis of mental health, substance use or concurrent disorder.
  • Require both the services offered at BTH and be in need of the rent supplement that accompanies BTH units.  
  • Be in receipt of sufficient funds to meet their financial and rent obligations. 
  • Have no legal restrictions on their ability to live within acceptable distances of schools and playgrounds.
  • Capable of consenting and participating in the program.

Referrals will not be considered if the following conditions are applicable in the client:

  •  1-1 supports to ensure safety of themselves or others 
  •  Individuals who are globally dependent on others for their ADL's 
  •  Diagnosis of developmental handicap, acquired brain injury, or neurocognitive disorders and some neurodevelopmental disorders* 
By checking this box, I attest that the above conditions have been met
 
FOR BACK TO HOME USE:
Date Received:
Select Date Clear Date
Hide/ShowClient/Patient Information
Is client aware of and agreeable to the referral?
Yes
No
 
First Name
Last Name
Preferred Pronouns:
DOB
Select Date Clear Date
Gender
Gender Identity
Address:
City
Postal Code
Client Contact Information:
Tel:
Permission to call?
Phone (Home/Main)
Permission to leave a message?
Phone (Home/Main)
Preferred Language
Language Interpreter required
Does client identify as:
Health Card Number:
Version:
Expiry:
Select Date Clear Date
Primary Diagnosis
Additional Diagnoses
Income source:
Hide/ShowConsent and Capacity

Indicate yes or no in each section regarding patients' capacity to consent. 

Medical Treatment
Yes
No
Finances
Yes
No
Psychiatric Treatment
Yes
No
Release of Information
Yes
No
Hide/ShowLegal
 
Current charges
Probation
CTO - Expiry date
Other:
If Other:
If CTO, please provide Expiry date:
Select Date Clear Date
Relevant details:
Hide/ShowReferral Source Information
Referral Source
Name:
Date:
Select Date Clear Date
Relationship to client/patient:
Contact Info:
Tel:
Email:
Fax:
 
Reason(s) for the referral
Current or future problems with:
Please select all that apply:
Precarious housing
IADL support
Stress and coping
Medication compliance monitoring
Substance use
Medical monitoring
Symptom management/relapse
Other:
ADL support
If Other:
Relevant details:
 
Psychiatric treatment and recovery history:
Substance use (current and historical):
Does client/patient want help with this?
Yes
No
Medical history:
See attached medication list/copy of medication administration record
Hide/Show Medication List (dummy_group)
Delete

Include prescription, vitamins, over the counter and herbal supplements.

Medication:
Dose:
Route:
Frequency:
Instructions/Comments
Hide/Show Medication List (1)
Delete

Include prescription, vitamins, over the counter and herbal supplements.

Medication:
Dose:
Route:
Frequency:
Instructions/Comments
Add Section Add Medication List
Hide/ShowActivities of Daily Living
Activity - Bowels
0 = Incontinent (or needs enema), 1 = Occasional accident (1 x week) , 2 = Continent
Score:
Activity - Bladder
0 = Incontinent/unable to manage, 1 = Occasional accident (max 1 in 24hrs), 2 = Continent (for over 7 days)
Score:
Activity: Grooming
0 = Assistance with personal care, 1 = Consistently requires prompting. 2 = Independent
Score
Activity - Toilet Use
0 = Dependent, 1 = Needs some help, 2 = Totally independent
Score
Activity - Feeding
0 = Unable, 1 = Needs assistance, 2 = Independent
Score:
Activity - Transfer
0 = Unable, 1 = Major (Assist of 1-2, physical), 2 = Minor (Assist of 1 verbal or physical), 3 = Independent
Score:
Activity - Mobility
0 = Immobile, 1 = Wheelchair (Independent), 2 = Walks with assist of 1 (verbal or physical), 3 = Independent (with or without aid)
Score:
Activity - Dressing
0 = Dependent, 1 = Assist (but can manage majority independent), 2 = Independent
Score:
Activity - Stairs
0 = Unable, 1 = Assist (verbal, physical, carrying aid), 2 = Independent up and down
Score:
Activity - Bathing
0 = Dependent, 1 - Assist of 1 - 2, 2 = Independent
Score:
 
For Back to Home Staff:
Total Sum:
Hide/ShowRisks and Vulnerabilities
 
Suicidal behaviour
Current:
Historical:
 
 
Physical violence
Current:
Historical:
 
 
Weapons use
Current:
Historical:
 
 
Verbal abuse or threats
Current:
Historical:
 
 
Substance use
Current:
Historical:
 
 
Rule adherence
Current:
Historical:
 
 
Self-harm behaviour
Current:
Historical:
 
 
Overdose
Current:
Historical:
 
 
Self-neglect
Current:
Historical:
 
 
Being victimized
Current:
Historical:
 
 
Medication adherence
Current:
Historical:
 
Relevant details:
Hide/ShowProtective Factors and Strengths
 
Social skills and relationships
Future oriented
Therapeutic alliance
Good coping and problem-solving skills
Occupational/recreational interests
Other
Good insight & judgement
Relevant details:
Hide/ShowCurrent Community Support Services

Please fill out the applicable fields.

Community psychiatrist name:
Tel:
Fax:
 
PG & T name:
Tel:
Email:
 
SDM name:
Tel:
Email:
 
P.O.A name
Tel:
Email:
 
List of current natural supports, support services, community agencies, and frequency:
?
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