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Service Information
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Service Information

Service:

CAMH@Home
Organization: Reconnect Health Services

Client Information

Client Name:

First name*

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Family/Last Name*

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Email Address:

Email (Confirmation and reminder emails will be sent here)

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Phone:

Primary Phone*

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Secondary Phone

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Address:*

Unit/Suite #*

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Street # & Street Name*

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City*

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Postal/Zip Code*

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Date of Birth:

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Year

Age: ( corrected)

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The age eligibility requirements for this service is:

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Substitute Decision Maker

Substitute Decision Maker Name:

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Substitute Decision Maker Info:

Primary Phone

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Secondary Phone

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Legal Relationships:

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Guardian

Substitute Decision Maker

Power of Attorney

Other

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Referral Source

Referral Source Name:*

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Family/Last Name*

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Referral SourceEmail Address:

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Referral Source Info:

Primary Phone*

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Secondary Phone

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Health Information

Diagnosis:

Primary Diagnosis

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Secondary Diagnosis

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Additional Information

Name of the person who can give more information about the client (if different than Substitute Decision Maker or Referral Source):

Phone number:

Health history, risk factors, and current status (if not attached below):

Please indicate health supports the client is being referred for. Please specify roles and tasks (e.g. physician for medication management, PSW for bathing, toileting, etc.), if not attached below:

Documentation:

Please attach a discharge summary including diagnosis, health history, risk factors and current status, if available. If not, please provide that information above.

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Are you sending any additional documentation separately by a method other than online through Caredove (e.g, via fax)?

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Consent

Does the client grant consent to send this referral?

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By clicking "Finish", you agree to send this personal information to Reconnect Health Services online.

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Notifications:

Send confirmation, change & reminder messages to < name > < email >

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To receive notifications, please select Yes.

Submission complete

The information has been submitted to Reconnect Health Services, but you have some steps left:

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Summary

Reference #: -

Registrant:
Organization:

Reconnect Health Services

Service:

CAMH@Home

Inquiry Phone:

1 (416) 248-2050

Tip: Referrals can be viewed by navigating to referrals in the top menu

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