Intake & Triage Form
North East Behavioural Supports Ontario

To be
completed by
Central Intake / Client identifier
Referral Type / New Readmission Re-admission within 60 days NEBSO LTC to IRT
Integrated Care Lead
TREATMENT DECISIONS MADE BY
Self (Competent) Legally Enacted Substitute Decision Maker (SDM) via POA PGTUnknown
Name / Relationship
Phone / City of Residence
Consent obtained verbally by (Name & designation)
Date / (dd/mm/yy) / Time (0000hrs)
North East BSO Inclusion Criteria: Enhanced service collaboration for…
Mandatory criteria
(select one) / Older adult presenting with responsive behaviour(s)
Individual with an age related disorder; presenting with responsive behaviours
Additional criteria
(select all that apply) / Behaviour(s) not effectively supported in current care environment
Mental health concern(s)
Diagnosis of Dementia
Substance use disorder
Other neurological disorder(s)
*Is client eligible? / Yes No
Preferred language to proceed with referral / English French Other:
CLIENT INFORMATION Male Female
Preferred language of client / English French Other: Interpreter Required? yes no
*Client name (first, last) / Phone / No phone
*DOB (dd-mm-yy) / Unknown / Health Card # / Unknown
*Primary Care Provider / No PCP / Phone / Unknown
Is the primary care provider/most responsible physician aware of this referral? / Yes NoUnknown
If no PCP, has the client been registered online with health care connect? / Yes NoUnknown
Living arrangements / LTC RR Community Other:
Permanent address
Current address / Since (dd/mm/yy)
IDENTIFY RESPONSIVE BEHAVIOUR & WHAT HAS CHANGED (THINK P.I.E.C.E.S.)
Nature of the change / recent (query mood disorder) gradual (query dementia) sudden (query delirium)
PLEASE SELECT ALL THAT APPLY *Adapted from the Cohen Mansfield Agitation Inventory
Pacing, wandering
Inappropriate dress/disrobing
Spitting (including at meals)
Cursing or verbal responsive behaviour
Constant unwarranted request for attention/help
Repetitive sentences or questions
Hitting - Self Others
Kicking
Grabbing onto people:
Pushing
Handling things inappropriately:
Hiding things
Making verbal sexual advances
Making physical sexual advances
Suicidal ideation/threat
Psychosis
Other: / Throwing things:
Expressive vocalizations (unusual laughter/crying)
Screaming:
Biting
Scratching
Trying to get to a different place (out of room)
Intentional falling
Complaining:
Negativism:
Eating/drinking inappropriate substances
Hurt self or other:
Hoarding things:
Tearing things or destroying property:
Performing repetitious mannerisms:
General restlessness
Other:
Other:
“PERCEIVED” LEVEL OF RISK Review R.I.S.K.S. from PIECES
Imminent / Immediate response. Almost certain death/serious injury/illness will result if action it not taken
High / 24hr response. Very likely harm will occur/re-occur is preventative measures are not put in place
Moderate / 72hr response. Potential harm will occur/re-occur if risks are not identified, managed and supports implemented
Low / 72+hr response. Unlikely harm will occur. Focus onprevention, reducing vulnerabilities & building capacities
Client Risk / Low Risk Moderate RiskHigh Risk Imminent Risk
Caregiver / Low Risk Moderate RiskHigh Risk Imminent Riskto be assessed by BSF
Current Primary Diagnosis
Co-morbid Diagnosis
It is preferred that a medication list be faxed to Central Intake Med. List to be faxed? Yes No
Current Psychotropic Medications / Dosage / Current Pain Medication / Dosage
Request for Geriatric Pharmacist review / Yes No To be determined by clinician
SUBSTANCE USE No history of use History unknown
History / alcohol illicit drugs prescription misuse tobaccoother:
Current / alcohol illicit drugs prescription misuse tobaccoother:
Notes
FUNCTIONAL STATUS
NAR (no assistance required) SAR (some assistance required) TAR (total assistance required)NA (not applicable)
Activities of Daily Living (ADL) / NAR SAR TARNA Other:
Instrumental Activities of daily Living (IADL) / NAR SAR TARNA Other:
SERVICES ACCESSED BY CLIENT/SDM
Previously / Currently / Awaiting
NE CCAC
Alzheimer Chapter
NE Specialized Geriatric Services
Senior’s Mental Health Outreach
BSO Team
Emergency Department visits
Other:
Has client been refused LTHC placement due to responsive behaviours / Yes No Unknown
EDUCATION REQUEST
Education request for staff / Yes NoUnknown, PRC to follow up
BSF involvement requested / Yes NoUnknown, BSF to follow up
PRIMARY CAREGIVER
Primary caregiver same as SDM (complete address section below and see contact information above)
Name / Phone
Address
REFERRAL SOURCE (identify who is providing information on the potential BSO client)
Name / Agency
Phone / Alternate Contact
WHAT ARE YOU GOALS IN MAKING THIS REFERRAL?
BSO POINT OF INTAKE (identify the BSO staff who is completing this Intake/Triage form)
Name / Agency
Date / First Point of Contact
Date triaged / Triaged to
Triaged via / Shared Drive In person Fax Other:
NE BSO CONTACT INFORMATION
Phone / 1-855-BSO NE13 (1-855-276-6313) / Fax / 705 675-8857 Additional info. attached # pgs

(Forms version 31/01/2013)

“As partners in care, we commit to and expect compassionate, timely and person-centered care”
– NEBSO August 2012