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Kardel
Kardel
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CRT Referral Form - New Item
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There are items in this form that require your attention
The CRT team coordinator will review online referrals to ensure:
1. The person being referred is eligible for service (WE DO NOT ACCEPT REFERRALS FOR INDIVIDUALS RECEIVING SERVICES THROUGH THE PSI STREAM).
2. The referral issue is sufficiently described to determine suitability for CRT services.
Referral Date
Individual
Person Being Referred
First Name
*
Last Name
*
Phone
Email
*
Date of Birth
*
Gender
Male
Female
Non-Binary
Street
*
City
*
Postal Code
*
Living Situation
Family Member
Group Home
Home Share
Independent/Semi-Independent
Who is making this referral?
Type:
Self-Referral
Referred By
Referred By: First Name
*
Referred By: Last Name
*
Referred By: Phone
*
Referred By: Email
*
Referred By: Street
*
Referred By: City
*
Referred By: Postal Code
*
Referred By: Organization
*
Referred By: Referrer Relationship
Family
Community Inclusion Program
Home Share
CLBC
Group Home
Specify your own value:
Other - Describe your involvement
Primary Care Contact
Primary Care: First Name
*
Primary Care: Last Name
*
Primary Care: Phone
*
Primary Care: Email
*
Primary Care: Organization
Primary Care Contact Relationship
*
Family
Community Inclusion Program
Home share
CLBC
Group Home
Specify your own value:
Other - Describe your Relationship
Community Inclusion Service Agency
Program
Program Address
Service Provided
Hours per Week
Contact First Name
*
Contact Last Name
*
Contact Position
*
Program Phone
*
Program Email
*
Community Involvement
Community Involvement (e.g. work/volunteer/school/respite)
Services Requested and Background Information
What services are being requested?
*
Behavioural support
Counselling
Provide a detailed description of the presenting issue including when the behaviour started, frequency, intensity, duration, where and when.
*
(300 words maximum)
Describe past and present strategies used to address the behaviour. Describe their effectiveness.
(300 words maximum)
List any previous behavioural, psychiatric, psychological, communication, or occupational therapy assessments.
(300 words maximum)
Consent and Witness
I have explained to the individual referred the nature of the consent request.
I hereby authorize the release of all pertinent information to the Community Response Team, the agencies, professionals, and people who are part of my support network. This consent will expire one year after submission.
Witness Name
*
Relationship
*
Date Witnessed
By submitting this referral form I confirm that I have obtained all necessary consents.
CRT Administration
Service History
Pending
Behaviour Consultant 1
Behaviour Consultant 2
Counsellor 1
Counsellor 2
Psychiatry
Active
Behaviour Consultant 1
Behaviour Consultant 2
Counsellor 1
Counsellor 2
Psychiatry
Behaviour Consultant Assigned Date
Behaviour Consultant Active Date
Behaviour Consultant Completed Date
Counsellor Assigned Date
Counsellor Active Date
Counsellor Completed Date
Psychiatry Assigned Date
Psychiatry Active Date
Psychiatry Completed Date
Completed Date
Entering a date will remove CRT referral from dashboard.
Comments
Intake Information
Referral Initiated By
Residential Service
CI Service
Family
Individual
CLBC
Specify your own value:
Primary Issue for Behavioural Referrals
Aggression
Property Destruction
SIB
Unsafe Behaviour in Community
Substance Use
Mental Health
Sexual Behaviour
Residential program breakdown
Day program breakdown
Specify your own value:
Primary presenting issue for Counselling Referrals
Grief
Emotional Regulation
Relationship Skills
Sexuality
Self-image/esteem
Adjustment to change in life circumstances
Specify your own value:
Special Project Type
PSI
Specify your own value:
Consent Expiry Date
Outcome
CRT Denied
Number of Counselling Sessions
Number of Missed Counselling Sessions
Outcome of Behavioural Referrals
BSP
BSSP
Consultation
Outcome
Attachments:
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