Sinai Health ED intake

Sinai Health Psych ED Partnership

by Reconnect Health Services

Client Information

First name

Last name

Date of birth

I don't know the client's date of birth

Country

Address

If no fixed address, please provide an address where the client can be found

Apartment/suite, P.O Box, etc.

City

Province

Postal code

Primary phone

Extension

Notifications will be sent to this address

Does not have an email address

Preferred spoken language

Reason for referral

Attachments

(Relevant documents, e.g. regarding medication, psychiatry assessments)

Client Health Information

Ontario Health Card Number (OHIP)

Version Code

Current supports (formal and informal)

Risk factors

Did the patient visit the ED or the After-Care Clinic?

Emergency Department

After-Care Clinic

Visit date

Referral Source Information

First name

Last name

Phone

Extension

Consent

By submitting this form, I agree to send this personal information to Reconnect Health Services, for the purpose of requesting service. I have the consent/authorization to send the information about any people that may be included on this form (e.g. client, patient, parent, child, friend, etc.)

I agree to these Terms and Conditions and Privacy Policy, which outline how this personal information is kept safe.

Sinai Health Psych ED Partnership

Client Information

Alternate Contact

Client Health Information

Referral Source Information

Consent