Coordinated Access to Care for the Homeless (CATCH-H)

CATCH-HPlease complete all sections of the referral and consent forms

FAX TO: 416‐864‐5467

Coordinated Access to Care for the Homeless (CATCH-H)

REFERRAL FORM

Primary, mental health and/or addictions care for people who are homeless and not adequately connected to health services

Client Information:

First Name:______Last name: ______Alt. Name(s): ______

Gender:□ Male □ Female □ Transgendered Date Of Birth: M ______D ______Y ______

Phone Number: ______Cell: ______Email: ______

Health Card #: ______Version Code: ______Province: ______

Person’s physical description: ______

______

Current or last known location/address: ______

______

Drop-in(s) or other agencies where this person spends the most time and best times when s/he can be reached at this/these locations:______

______

The client has consented for us to contact the following individuals or organizations:

Telephone number(s) where s/he can be reached / What kind of phone number is this?
(e.g., personal, shelter, friend/family, drop-in; provide additional names/information if applicable) / Best times when he/she can be reached at this telephone number(s)

Health Profile:

Mental health (list relevant diagnostic information): ______

Physical health (list relevant diagnostic information,inc. communicable diseases, e.g., TB, MRSA, lice, mobility issues):______

Substance use(list substances, IV use if any):

______

Please complete all sections of the referral and consent forms

FAX TO: 416‐864‐5467

Medications(list medications taken, inc. doses and frequency of administration):

______

Medications prescribed by: ______

Service Needs:

Does the person have a Family Physician or Psychiatrist?□ Yes□ No

If yes:

Name:______Specialty: ______Phone: ______

What type of assistance does this client need?(check all that apply)

□Family physician □Psychiatrist □Mental Health case management

Support Services:

Does the person have a case manager or support worker?□ Yes□ No

If yes:

Name:______Agency: ______Phone: ______

Safety Alerts:

History of aggression: □ Yes □ No

If yes, please explain:______

______

If applicable, Probation/Parole Officer name: ______Phone: ______

Other Relevant Information:

______

CATCH-HPlease complete all sections of the referral and consent forms FAX TO: 416‐864‐5467

Coordinated Access to Care for the Homeless (CATCH-H)

CONSENT FORM A

Client Consent* to the collection, use and disclosure of Personal Health Information

CATCH-H is a partnership between St. Michael's Hospital, Inner City Health Associates and Toronto North Support Services. These organizations work together and collaborate with other health and social serviceagencies, such as the GoodShepherdCenter and the Parkdale Activity Recreation Center Peer Support Program to help connect people who are homeless to health resources in the community. To protect your privacy, CATCH-H follows the Ontario Personal Health Information Protection Act. None of your Personal Health Information will be collected or shared with any person other than those involved in your care, except with written consent or if required by law.

I consent to collection and use of information (including diagnostic and needs assessments, reports from service providers, discharge plans) between the referring hospital / agency and CATCH-H for the purpose of:

Coordinating your care between CATCH-H partners
Assessing your needs
Developing plans of care and matching to appropriate supports

I understand that I may withdraw my consent at any time by giving notice in writing to my CATCH case manager. Once I withdraw consent, my Personal Health Information shall no longer be shared or disclosed to CATCH partners.

Client Name: ______

Client signature: ______

Date (MM/DD/YY): ______

*If applicable, Substitute Decision Maker’s (SDM) name:______

SDM’s signature: ______Date (MM/DD/YY): ______

CATCH-HPlease complete all sections of the referral and consent forms

FAX TO: 416‐864‐5467

Coordinated Access to Care for the Homeless (CATCH-H)

CONSENT FORM B

Client Consent* to the release of information by contact persons or agencies

We would like you to contact the CATCH-H Coordinator with any update about your living situation. You can use a toll-free phone number, 1-877-482-4595, for these phone calls.

In the referral form, you have given us the names and contact information of friends, relatives, service providers or other people who might know where you are if we are not able to get in touch with you when it is time for your follow up appointment. We will be asking these people only about your location and contact information and only when we don’t know where you are and are trying to find you to schedule an appointment. We will tell these individuals that we are trying to get in touch with you for the purpose of helping connect you to health resources, but we will not share any of the information you have provided in the referral form or any other personal information.

I consent to the CATCH-H partners contacting the individuals or organizations I named on the referral form. I authorize these people to release information regarding my up-to-date mailing address and phone number to the CATCH-H partners.

Client Name: ______

Client signature: ______

Date (MM/DD/YY): ______

Referral Source Information:

I have explained the consent to the client and provided the client and/or SDM with an opportunity to ask questions that I answered.

Name of person making referral:______Date (MM/DD/YY): ______

Hospital / Agency:______Department: ______

Phone: ______Pager: ______Email: ______

Has the client given consent to this referral being made? □ Yes□ No

*If applicable, Substitute Decision Maker’s (SDM) name:______

SDM’s signature: ______Date (MM/DD/YY): ______

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