BC Mental Health & Substance Use Services Referral Package Please indicate which program(s) you would like your client to be considered for: Provincial Substance Use Treatment Program Revised: September 8, 2017
Referral Package Completion Checklist Please note: This package is intended to be completed by a community support team member or a health care professional in collaboration with the client. Before submitting this package to your local Health Authority for processing, please ensure the following tasks are complete: Complete the included referral form, leave no boxes blank. Include the following collateral information if available and applicable: Current psychiatric and/or medical consult Hospital admission/discharge notes Recent psychiatric consults AWOLs, pass levels Substance Use pattern (prior to hospitalization if relevant) Relevant discharge summaries Forensic assessments (if applicable) Counsellor notes Current MAR Current Mental Health certificates (if applicable) In consultation with the client, complete and attach the Early Exit Transition Plan form and Participation Agreement. Please ensure it is signed. Attach current funding for the duration of the program including coverage for medications while in treatment. TB test (if available) Review program appropriate resident guide with client The above components constitute a completed referral and will be reviewed by the program Admission Committee once received from the Health Authority screening committee. Referral Information Package Mandate BC Mental Health & Substance Use Services, an agency of PHSA, provides a diverse range of specialized and one-of-a-kind tertiary mental health and substance use services for individuals across the province, including the provision of residential substance use treatment beds for adults ages 19 years and older in British Columbia who are experiencing serious, chronic patterns of substance use Inclusion Criteria Problematic substance use Severe/complex substance use BC Resident Age 19+ Gender All Medically and Psychiatrically Stable (not requiring acute hospitalization) Activities of Daily Living: Clients need to have the ability to be independent in their activities of daily living including eating, toileting, and mobilizing. Mental Health and Addiction Team or a Community Care Team Connection: 2 Page
Additional Considerations Exclusion Criteria Program Transition/Discharge Criteria The following will also be considered when assessing clients for appropriate treatment match and timing To ensure safety for all, client mix will be considered (e.g. number of clients with medical, behavioural, or mental health concerns)) A recent history of physical violence Acute suicidality The referring health authority must prioritize clients for access to provincial substance use treatment. Please contact the Access and Flow Coordinator or Health Authority Liaison for discussion if unsure about exclusion criteria Complex mental health needs Sexual offences involving minors Severe violence including sexual violence Arson/Fire setting Referral Process Requests regarding early transitions/discharge from treatment program may include the following Physical, sexual or verbal threats/abuse/violence Drug dealing/sharing Alcohol or drug use premises or used on outings with staff Attempted/recruitment of others into gangs or the sex trade Recruiting co-clients into illegal or harmful activities Persistent drug and alcohol use in program Referrals can be completed by a community support team in collaboration with the client: Counsellor Psychiatrist Social Worker Community mental and addiction health team provider Physician Psychologist The Referring Professional/Case Manager will forward the completed referral package to their Health Authority Liaison. If the Health Authority screening process approves the client s referral, it is then sent to the Access and Flow Coordinator at the designated BC Mental Health and Substance Use Services site. Once all required information is received, the clinical team reviews the referral within 1-2 weeks depending on program demand and volume of referrals. The Admission and Aftercare Committee will determine the most appropriate facility to best support the individual s needs. The decision is based on the information provided in the referral package along with any additional information that has been provided to the committee. The treatment match outcome for the referral will be communicated to the Health Authority Liaison by the Access and Flow Coordinator. A formal email communication will be provided to the Health Authority Liaison for clients who do not meet admission criteria for the referred BC Mental Health and Substance Use Services treatment program. In the instance where another BCMHSUS program is a better match, the Liaison will be advised and the referral will be forwarded to the suggested program. When accepted, the Health Authority Liaison will place the client on a waitlist. If a bed is immediately available, the referring agent or Case Manager will be advised of the client admission date. If you have further questions please contact your Health Authority Liaison who will be able to assist you in completing the form and provide you with further information. Please forward the completed referrals to the specific Health Authority Liaison as detailed below: Health Authority Liaison Contacts Liaison Email Phone Fax Fraser Health Authority Libby Leddy elizabeth.leddy@fraserhealth.ca 604 614 2383 604 517 8656 Interior Health Authority Jamie Marshall Jamie.marshall@interiorhealth.ca 250 469-7070 Ext: 12166 250 868 7770 Island Health Authority Dana Leik Dana.Leik@viha.ca 250 755 7691 Ext. 54776 250 740 2689 Northern Health Authority Doug England Doug.england@northernhealth.ca 250 645 6088 250 649 7219 Vancouver Coastal Health Authority Andrew Stone Andrew.stone@vch.ca 604 675 2455 604 681 1894 Provincial Access & Flow Coordinator Jennifer Lowrey jlowrey@bcmhs.bc.ca 604 829 8658 3 Page
Referral Information Date of referral (day/month/year): Client s Legal Name: Preferred Name(s): Health Authority: IHA FHA NHA PHSA VCHA VIHA FNHA If the client is being referred through First Nations Health Authority, what Regional Health Authority do they reside in? IHA FHA NHA PHSA VCHA VIHA Referring Source: If referring source is a hospital, please list name of hospital and unit: Referring Organization: Telephone: Fax: Email: MH&A Case Manager: Ph: Fax: Email Address: Physician Name : Ph: Fax: Client Information Date of Birth: Age: PHN: Female Male Self-identification: Current Address: City: Province: Postal Code: Telephone: Email: Marital Status: Married Common Law Single Divorced Separated Widowed Cultural Information Do you identify yourself as an Indigenous person that is First Nations, Metis or Inuit? Yes No If you identify as an Indigenous person are you: Indigenous First Nations Metis Inuit Status: Yes No Status #: Band: Ethnicity (German, Spanish, etc.): First Language: Is there a need for an Interpreter? Yes No 4 Page
We invite you to let us know if there are any spiritual or religious practices or ceremonies that will support your wellness while in treatment: Emergency Contact Person (Family/Friend) (Please note that the person below will be contacted should there be an emergent concern about safety, medical, etc.) Name: Telephone: Relationship: Email: Is there an identified Substitute Decision Maker (SDM)? Yes No Name: Telephone: Email: Power of Attorney/Trustee Is there a Power of Attorney in Place? Yes No If yes, provide a brief description: (e.g. finances, treatment decisions, etc.) Is there a Trustee? Yes No Name: Telephone: Email: 5 Page
Family Involvement Do you have children? Yes No Number of Children: Minor: Adult: Are your children in foster care? Yes No Are you a custodial parent? Yes No Name of custodial/foster parent(s): Phone/Email of custodial parent : Names of Children Age If child is minor, what is their current living situation? Please provide details, including contact information and MCFD contact information (if appropriate): Telephone: Fax: Email: Yes No Elder Care? If yes, please provide details on what supportive arrangements have been made: Are there any other family members that are important to your wellbeing? Yes No If yes, please provide details below: 6 Page
Independent Housing Safe Unsafe Stable Unstable Current Housing (e.g. house, apartment, family, parents, SRO, etc.) Supportive Housing Safe Unsafe Stable Unstable Type: (e.g mhsu housing, semi-independent living) Transitional housing Safe Unsafe Stable Unstable Type: (e.g. support recovery, stellars) Type: Homeless/Inadequately/Housed/Shelter/ Couchsurfing (e.g. Friend s home, parents, etc.) - Please provide name of facility Type: Will the client be able to return to the current living situation? Yes No If no, please explain: Post-discharge housing plan? Safe Stable Unsafe Unstable Details: Education Describe any challenges to participating in a group setting: Education Level: Presently enrolled in school. Grade: High school grade completed Completed high school Post-secondary 7 Page
Substance Use Treatment Treatment History (Please list all previous treatment and dates): If no previous residential treatment history, is this due to lack of services available in community? Yes No If no, please tell us why treatment at a different facility is not being considered at this time: Substance Use Please fill this section out completely. Please put N/A next to the item if not applicable Drug of choice (circle top 3) Primary or Route Current Pattern (e.g. binge, occasional) Date last used (DD / MM / YY) # Days used in last 30 days Typical amount used daily Alcohol Non-beverage alcohol (mouthwash) Amphetamines XTC GHB Benzo Age at 1 st use Cannabis Cocaine Crack Cocaine Crystal Meth Fentanyl Hallucinogens Heroin Inhalants Other Opioids Tobacco (including vaping / e-cigarettes) Other (Specify): 8 Page
Gambling Sexual activity Pornography Shopping Shoplifting Internet Gaming (including online) Social Media Strengths Treatment Goals This section should be completed in collaboration with the client and their community support team 9 Page
Medical History Environmental, Food, Medication Allergies: Yes No If yes, provide a brief description and type of reaction(s) and treatment needed Pregnant: Yes No Number of weeks pregnant: Independent of ADLs Yes No Details: Do you have any history of disordered eating? Yes No If yes, please define: Binge Eating Vomiting Restricting Laxatives Excessive exercising Other, please describe: Have you ever participated in treatment for disordered eating? Yes No Is your disordered eating still active? Yes No When last active: Medical Dietary Concerns: Yes No If yes, provide a brief description: Do you have any dietary requirement? Yes No If yes, provide a brief description: Mobility Issues: Yes No If yes, please indicate if any ability aids are being used below: Fall Risk: Yes No Prosthesis: Yes No Head Injury FASD/ Visual Impairment Hearing Impairment Yes No Details Yes No Details Yes No Details Yes No Details 10 Page
Current and chronic diseases (e.g. Diabetes, COPD, etc.) Yes No If yes, provide a brief description: Have you had surgery within the last two years? Yes No If yes, provide a brief description: Do you have any scheduled surgeries, dental appointments or specialist appointments? Yes No If yes, provide a brief description: Delirium Tremors Yes No Withdrawal History Seizures associated with withdrawal: Yes No Date of last seizure: Hospital admissions for withdrawal Yes No Please describe: Please describe any other withdrawal complications (e.g. opioids) Psychiatric Diagnoses (Axis I): Mental Health History Personality Disorders and Developmental Disabilities (Axis II): Note: For head/brain injury/fasd or cognitive impairment: provide a brief description of cognitive disabilities and attach any collateral assessment/reports (e.g. most recent assessment(s) from psychiatry, O.T, psychology etc.) Is the client connected to CLBC? Yes No Contact Person: If yes, provide a brief description: 11 Page
Psychosocial and Environmental Concerns (Axis IV): Global Assessment of Functioning (Axis V): History of Substance Induced Psychosis: History of Aggression: Yes No If yes, please attach a brief description of history of verbal and/or physical aggression incidents, outcomes and last occurrence (e.g. throwing objects, yelling, under the influence of substances). Effective Intervention(s): 12 Page
Current Medications (Please attach a Medication Administration Record or provide information below) Medication and dose Date Started Prescriber Medication and dose Date Started Prescriber Currently on ARV Treatment? Yes No Have ARV medications been ordered for treatment setting? Current Safety Concerns If yes to any below, please provide the date of most recent along with details for each one Yes No Suicide Ideation/Suicide attempts: Yes No Self-harming behaviours: Yes No Accidental Overdoses: Yes No Aggression/anger: Yes No Interpersonal/Domestic violence: Yes No Sex-trade work: Yes No Disordered eating behaviours: Yes No Flight Risk: Yes No 13 Page
Legal Is the client supervised by a probation officer? Yes No Probation Officer s contact name: Phone: Are there any conditions that we need to be aware of to support client s stay? Yes No Please provide details below: Upcoming court dates: Location: Please provide details (e.g. transportation required, technological requirements, etc.): 14 Page
Early Exit Transition Plan The following plan will be put in place if I leave treatment early. I understand that as I continue treatment, the program will assist me to develop a more complete transition plan to ensure my continued support and recovery when returning home. It is understood that if I leave the program on short notice or if I do not arrive for my scheduled intake, my referral liaison and my emergency contact will be notified immediately. Client Name: Key Community Contact for Transition Plan Name/Relationship: Telephone: Emergency Contact and/or Next of Kin Name/Relationship: Telephone: Community / Health Authority Contact Name/Agency: Email: Email: Telephone: Email: Weekday Early Exit Discharge Plan Destination Contact Name/Relationship: Weekend Early Exit Discharge Plan Destination Contact Name/Relationship: Destination Address: Destination Address: Destination Phone number: Destination Phone number: Own transport to/from program? Yes No Own transport to/from program? Yes No If no, who will transport? (name, phone, relationship) If no, who will transport? (name, phone, relationship) Mode of Transportation (please provide plane, bus, letter of confirmation for transportation): Mode of Transportation (please provide plane, bus, letter of confirmation for transportation): Signatures By signing below, I consent to my referral liaison and emergency contact being contacted. I also understand that if I leave the program early, my physician will be sent an early discharge summary. Client: Date: Referral Agent agrees to collaborate with the client to ensure they reconnect with their community services upon discharge within the Health Authority that this referral was originated. Referral Agent Name: Referral Agent Signature: Date: 15 Page