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108 Rue du Christ Roi, Maniwaki, QC J9E 1C3

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Pour les champs non obligatoires, le répondant peut fournir les informations à sa discrétion.

1
PERSONAL INFORMATION
2 REFERRAL OBJECTIVE
3 HEALTH PROFILE
4 FINANCIAL AND MEDICAL INFORMATION
5 PERSON INFORMATION
6 DOCUMENTS AND SUBMISSION

GENDER

MALE

FEMALE

N/A

LANGUAGE

ENGLISH

FRENCH

PERSONNE FOR INTERVENTION

MEDICAL DOCTOR

SIGNIFICANT OTHER

MENTAL HEALTH

HOMELESSNESS

DEPENDENCIES

SITUATIONAL VULNERABILITY

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MENTAL HEALTH ACCOMMODATIONS MANIWAKI DAY CENTER GRACEFIELD DAY CENTER MENTAL HEALTH EXTERNAL FOLLOW UP

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ACCOMODATIONS URGENCY (CHAMBRE) ACCOMODATIONS FOR STABILISATION (STUDIO) HOMELESS EXTERNAL SERVICES

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MOBILE SERVICES

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ADAPTIVE TRANSPORTATION MOBILE RESOURCES

BRIEF DESCRIPTION OF FOLLOW UP

APPLIED RESOURCES AND/OR INTERVENTION

MENTAL HEALTH DIAGNOSTIC (IF APPLICABLE)

NUMBER OF HOSPITALIZATION

DATE OF START OF HEALTH CHALLENGES

INTELLECTUAL DEFICIENCY

YES

NO

DEGREE

LIGHT

AVERAGE

HEAVY

COURT ORDER

PHYSICAL CONDITION AND/OR ILLNESSES

PRESENT INFECTIOUS DISEASES

YES

NO

N/A

PLEASE INDICATE

VIOLENCE INVOLVING POLICE INTERVENTION

YES

NO

N/A

POLICE VERIFICATION AUTHORIZATION

YES

NO

N/A

LIVING ENVIRONMENT

FAMILY

AUTONOMOUS

HOSPITALIZATIONS

NO FIXED RESIDENCE

OTHER

STATUS EMPLOYMENT REVENUE

DOES THIS PERSON HAVE THE MEANS TO PAY ACCOMMODATIONS

YES

NO

PRESCRIPTION MEDICATION DOSAGE & PRN

ACCEPT AND UNDERSTANDS THE NEED FOR MEDICATION

YES

NO

N/A

UNDERSTAND THE MEDICATION AND SIDE AFFECTS

YES

NO

N/A

CAN TAKE MEDICATION INDEPENDENTLY

YES

NO

N/A

NEEDS FREQUENT P.R.N

YES

NO

N/A

HAS CHILDREN

YES

NO

N/A

CONTACT WITH FAMILY

YES

NO

N/A

SUICIDE RISK

YES

NO

N/A

VIOLENCE OR AGRESSION

YES

NO

N/A

COOPERATES GENERALLY WELL

YES

NO

N/A

EXPRESS THEIR NEEDS WELL

YES

NO

N/A

MOTIVATED BY CHANGE

YES

NO

N/A

CAN MANAGE OWN BUDGET

YES

NO

N/A

RECOGNIZES SYMPTOMS, STRESSERS AND WARNING SIGNS ASSOCIATED TO A RELAPSE OR HARM TO HIMSELF

YES

NO

N/A

MAINTAINS A GOOD CONTACT WITH THEIR INTERVENOR

YES

NO

N/A

PSYCHIATRIC ASSESSMENT OR/AND CASE SUMMARY

PHYSICAL ÉVALUATION WITHIN THE LAST 6 MONTHS

OTHER

SIGNATURE OF REFERER

SIGNATURE PERSON REFERRED

CONTACT US

OUR ADDRESS

108 Rue du Christ Roi, Maniwaki, QC J9E 1C3

CONTACT

(819) 449-6777

EMAIL

info@maisonamitie.ca

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