Selkirk Mental Health Centre
Acquired Brain InjuryProgram Referral Form

Date: ______

Section 1: Personal Data:

Name: / Gender: ? Male Female
Date of Birth (month/day/year) / Address:
MB Health # / Phone:
PHIN # / Marital Status:
Primary Language Spoken: / Treaty Status:
MPI Claim #:
MPI Case Manager: / Public Trustee Officer:
Legal Status:
Voluntary ? No Yes
Form 9 ? No Yes
Form 10? No Yes
Involuntary ? No Yes
Treatment decisions made by: / Order of Supervision:? No Yes
If yes, date issued:______
Order of Committeeship: No Yes
If yes, please attach copy.
Health Care Directive completed: ? No Yes
If yes, please attach copy.
Source of Income: / Employment and Income Assistance #:
Employment and Income Assistance Worker:
Next of Kin: / Relationship:
Address: / Phone:
Home:
Work:
Mobile:

The following information will help us understand the above patient. Please answer each question as fully as possible.

Section 2: Medical Data

  1. What is the cause of the acquired brain injury? ______
  1. What is the date of injury?______
  1. Past Medical History (e.g. additional diagnoses, allergies, seizures, disabilities)
  1. Is there an ongoing or history of mental health issues? ? No Yes

If yes, please comment.

  1. Is there an ongoing or history of drug and/or alcohol use?? No Yes

If yes, please comment.

  1. Medications and Treatments (include name, dosage and compliance)
  1. Vaccinations:
  2. Pneumococcal Vaccine given? ? No Yes

Date: ______

  1. Mantoux Test Completed?? No Yes

Reading: ______Date:______

  1. History of Bacillus Calmette G?? No Yes

Date:______

Section3: Pre-Injury Data

  1. Pre-Injury Living Arrangements (e.g. with whom, type of setting)
  1. Highest Level of Education
  1. Employment History (please indicate place and dates of employment)
  1. Interests/Hobbies
  1. Did the patient require assistance/equipment prior to their injury to complete daily activities? If yes, please explain.
  1. Family Involvement and/or Other Support Systems
  1. Legal Issues

Section4: Post injury Data

Please have each question completed by appropriate discipline, if available.

  1. Has the patient received previous rehabilitation? ? No Yes

If yes, please indicate the services that were received:

DatesLocation

Occupational Therapy (OT)______

Physical Therapy (PT)______

Speech Therapy (SLP)______

Neuropsychology ______

Other ______

  1. Describe the patient’s level of participation in the above services.
  1. Can the patient follow basic one-step commands? ? No Yes
  1. Does the patient have any difficulty completing personal care (e.g. bathing, dressing, feeding, or toileting)?If yes, please describe.

(To be completed by OT if available)

  1. Describe patient’s current transfer and mobility status.

(To be completed by PT if available)

  1. Describe the patient’s current communication skills.

(To be completed by SLP if available)

  1. Has a swallowing assessment been completed? ? No Yes

If yes, please indicate when and results.

(To be completed by SLP if available)

  1. What is the patient’s current diet?

(To be completed by SLP or Clinical Dietitian if available)

  1. Behavioral Issues? No Yes

If yes, please list known triggers andlist/describe effective interventions used.

Section 5: Referral Source

  1. Reason(s) for Referral

______

______

______

______

  1. Is the patient agreeable to ABI admission? ? No Yes

If no, why not?

  1. Is the family agreeable to ABI admission? ? No Yes

If no, why not?

Date family consulted regarding admission ______

  1. Does the patient wish to tour ABI program?? No Yes
  1. Does the family wish to tour ABI program?? No Yes

Section6: Patient/Family Goals & Services Requested

  1. What ABI services are being requested?
  1. Occupational Therapy ?No ? Yes
  2. Physical Therapy?No ?Yes
  3. Speech Therapy ? No ?Yes
  4. Neuropsychology ? No ? Yes
  5. Social Work ? No ? Yes
  6. Other (please specify)
  1. What are the patient’s self identified goals?
  1. What are the family’s goals for the patient?

4. Describe the level and nature of family involvement?

Section 7: Discharge

  1. Current viable post-discharge option/location.
  1. Patient/family post-discharge placement preference
  1. List other discharge sites attempted/referred to (include dates).

Section 8: Attachments

Please ensure the following are attached in order to assist the intake team with making a decision.

a. Physical Examination?No ?Yes

b. Consultation Reports?No ?Yes

c. Laboratory & Diagnostic Imaging Reports?No Yes

(including CT scans, MRIs of head)

d. Intensive Care Transfer Summary?No ?Yes

e. Operative Reports/ER report w/GCS?No ? Yes

f. Neuropsychological/Psychological Reports? No ?Yes

g. OT/PT/SLP Assessments/Reports? No ?Yes

h. Social History ? No ? Yes

Other Comments:

______

______

______

______

______

Name of Referring Source/DesignationPhone Number

______

Referral AgencyDate

Please complete and forward by mail (DO NOT FAX) to the address below.

Program Manager

ABI Program

Selkirk Mental Health Centre

Box 9600

SELKIRKMB R1A 2B5

FOR PROGRAM USE ONLY:

Date Referral Received: ______Date Referral Accepted: ______

?Referral Not Accepted - Reason: ______

Comments: ______

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CR 009A

Rev. June 2011