Newgate 180 | Residential Services Referral Form

Name: Date Of Birth:

Street Address: City:

Province: Postal Code:

Home Phone: Alternate Number:

Emergency Contact: Emergency Phone:

Referral Information

Referral Date:

Referral Agency: Contact Name:

Phone Number: Extension: Fax Number:

Treatment Mandated/Required By: Legal Status:

Pending Legal Charges: Court Date:

Relationship Status: Employment Status:

Level Of Eductaion: Source Of Income:

Presenting Issues At Admission: Alcohol Drugs Gambling

Presenting Problem Substances:
Substance #1: Past 30 Day Usage:
Substance #2: Past 30 Day Usage:
Substance #3: Past 30 Day Usage:

Substances Used In The Past 12 Months:

Problem Gambling Activities In The Past 12 Months:

Health Status/Problems:

Number of hospitalizations in the past 12 months for physical health problems:
Reason(s) for hospitalization:

Diagnosed with a mental health problem by a qualified mental health professional? No Yes
If yes, Within the last 12 months Within a lifetime

Most recent diagnosis #1:
Most recent diagnosis #2:

Hospitalized for a mental health problem? No Yes
If yes, Within the last 12 months Within a lifetime

Received treatment for mental health, emotional, behavioral, or psychological problem from community mental health program/professional? No Yes
If yes, Currently Within the last 12 months Within a lifetime

Health concerns:

Drugs Currently Prescribed: (list all prescribed and OTC medication by classification, eg. antidepressant, diuretic)
#1: #2:
#3: #4:
#5: #6:

Clinical Observations and recommendations:

Does client have welcome kit?

Is he aware that if he arrives intoxicated he will be referred to Detox?