Akyaung Ari Naga	Asked But Declined
Chinese	English
French	Halh Mongolian
Hindi	Italian
Other	Portuguese
Unknown

If other: If not comfortable speaking in English is an interpreter needed: Choose One Yes No Unknown

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Social Determinants of Health

Primary Ethnicity * Choose One Asian - East (e.g. Chinese, Japanese, Korean) Asian - South (e.g. Indian, Pakistani, Sri Lanken) Asian - South East (e.g. Malaysian, Filipino, Vietnamese) Black - African (e.g. Ghanaian, Kenyan, Somali) Black - Caribbean (e.g. Barbadian, Jamaican) Black - North American (e.g. Canadian, American) Do Not Know First Nations Inuit Indigenous/Aboriginal - not included elsewhere Latin American ( e.g. Argentinean, Chilean, Salvadoran) Metis Middle Eastern (e.g. Egyptian, Iranian, Lebanese) Mixed Heritage (e.g. Black-African & White - North American) Other White - European (e.g. English, Italian, Portuguese, Russian) White - North American (e.g. Canadian, American) Indian - Caribbean (e.g. Guyanese with origins in India) Additional Ethnicities If other Religion If other:

Highest Level of Education	Choose One Primary school started but not finished Received elementary school education Educated to secondary school level Educated to junior high school level Educated to senior high school level Educated to high school level Received education at technical college Received graduate education Received postgraduate education Received higher education college education Received university education Attending university Education interrupted No formal education Other Unknown Asked But Declined
Education Status	Choose One Not in school Elementary/Junior High School Secondary/High School Trade School Vocational/Training Centre Adult Education Community College University Other Unknown or Service Recipient Declined
Employment Status *	Choose One Self-employed Income support Permanently unable to perform work activities due to medical condition In paid employment In paid casual work Does voluntary work Not in labor force Retired In sheltered work Employment retraining Unemployed Other Asked But Declined Unknown
Income Source *	Choose One Disability Assistance (Insurance) Employment Employment Insurance Family No source of income ODSP (Ontario Disability Support Program) Other Insurance (excluding Employment Insurance) Pension (Retirement Income) Social assistance (Ontario Works) Asked But Declined Other Income Sources Do not know
Total Household Income *	Choose One $0-$19,999 $20,000-$29,999 $30,000-$59,999 $60,000-$89,999 $90,000-$119,999 $120,000-$149,999 $150,000 or more Asked But Declined Do not know
Number of People Income Supports *
Living Arrangements *	Choose One Self Spouse/partner Spouse/partner and others Childern Parents Relatives Non-relatives Unknown or Service Recipient Declined
Residence Type *	Choose One Lives in own home Lives in rented accommodation Boarding House Correctional Facility Homeless Group Living Sheltered Housing Hostel Supportive living Hospital Asked But Declined Other Do not know
Residence Status:	Choose One Independent Assisted/Supported Supervised Non-facility Supervised-Facility Unknown or Service Recipient Declined

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Legal Issues

Legal Status Legal Issue Detailed

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Diagnostic Categories

Pre-Existing Conditions

Neurodevelopmental Disorders	Schizophrenia Spectrum and Other Psychotic Disorders
Bipolar and Related Disorders	Depressive Disorders
Anxiety Disorders	Obsessive-Compulsive and Related Disorders
Trauma and Stressor-Related Disorders	Dissociative Disorders
Somatic Symptom and Related Disorders	Feeding and Eating Disorders
Elimination Disorders	Sleep-Wake Disorders
Sexual Dysfunctions	Gender Dysphoria
Disruptive, Impulse-Control, and Conduct Disorders	Substance-Related and Addictive Disorders
Neurocognitive Disorders	Personality Disorders
Paraphilic Disorders	Other Mental Disorders
Medication-Induced Movement Disorders and Other Adverse Effects of Medication	not applicable
Unknown	Asked but Declined

Age of onset for Mental Illness		Not Applicable
Age of first Hospitalization		Not Applicable

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Referral Source

Referral Source * Bounce Back ACTT ACTT (SHIP) ACTT (Trillium) Alzheimer's Society - Dufferin Applewood Heights Secondary School ASP Behavioural Community Support ASP Behavioural Support Counselling ASP Directed ASP Psychogeriatric Counselling Associated Youth Services of Peel Bail Desk Bartimaeus Baycrest Bayview Community Centre BCCL Bloorview Kids Rehab Brampton Caledon Neighbourhood Services Brampton Centenial Secondary School Brampton Civic Hospital Brampton Parks and Recreation Bridgepoint Hospital BSO (Behavioural Supports Ontario) Bus Tickets - Brampton Bus Tickets - Mississauga Caledon Community Support Services CAMH CAMH - Lakeshore Clinic CAMH - Peel Dual Diagnosis Program Camilla Care Community Cardinal Leger Secondary School Carpe Diem CAS Catholic Cross Cultural Services Catholic Family Services of Peel Cawthra Road Shelter CCAC CCAC Health Links CCAC Health Links - Bolton/Caledon CCAC Health Links - Brampton/Bramalea CCAC Health Links - Child & Family CCAC Health Links - Dufferin CCAC Health Links - NEWWM CDRCP Central East Correctional Centre Central North Correctional Centre Central West Network of Specialized Care Children's Hospital Children's Program Christian Horizons Citizenship Immigration Canada City of Brampton City of Mississauga CLM Clothing CMH & Addiction CMH Early Psychosis Prgm CMH Family Support Initiative CMH Homes for Special Care CMH Supported Housing CMHA Halton CMHA National CMHA ON CMHA Other Branch CMHA Peel 24.7 CMHA Peel ACT CMHA Peel ATR CMHA Peel Bridging Addiction CMHA Peel Central Intake CMHA Peel Counselling & Treatment - Access CMHA Peel Counselling & Treatment - Dufferin CMHA Peel Counselling & Treatment - Rexdale CMHA Peel Dufferin DBT CMHA Peel Dufferin - CCC: Individual CMHA Peel Dufferin - EPI CMHA Peel Dufferin - Mental Health Consultants CMHA Peel Dufferin RAAM CMHA Peel Dufferin - SARSC CMHA Peel Dufferin - SGS CMHA Peel Dufferin - SICM CMHA Peel Dufferin - Support Coordination CMHA Peel Dufferin Addictions Treatment - Access CMHA Peel Dufferin Addictions Treatment - Caledon CMHA Peel Dufferin Addictions Treatment - Rexdale CMHA Peel Eden Place CMHA Peel Familty Initiatives - Access CMHA Peel Familty Initiatives - ACT CMHA Peel Familty Initiatives - FP+ CMHA Peel Familty Initiatives - Launch CMHA Peel FP+ CMHA Peel Impact CMHA Peel InSTED CMHA Peel McEvenue Home Works CMHA Peel MHJS CMHA Peel Mobile Health CMHA Peel Outreach CMHA Peel Recovery West CMHA Peel Short Term CMHA Peel Support within Housing CMHA Peel Transitional Support CMHA Peel Wait List CMHA Peel Web Site CMHA Peel Youth Net CMHA Treat at Home CMHA WW CODA Community Community Care Access Centre - MHAN Community Health Community Living Mississauga Community Living Peel Community Paramedic Program Community Residential - excl. Substance Abuse Complementary Therapy Cons./Survivor Support Network (Drop-in) Cons./Survivor Support Network (Self-help) Contact Hamilton Counselling County of Dufferin County of Dufferin - Housing Court Personnel Court Social Worker COVID@Home Credit Valley Hospital Crown Attorney CWSDS CWSDS Dual Diagnosis Service David Suzuki Secondary School DBT Defense Counsel Detox DSO Dufferin Area Family Health Team Dufferin Child and Family Services Dufferin Community Support Dufferin Courthouse Dufferin Situation Table Dufferin-Peel Separate School Board Dundas Street Shelter (old PFS) Duty Counsel East Mississauga Community Health Centre Eden Community Food Bank Educational Institutions Elizabeth Fry Ellen House Employer Erinoak Escort Officer Etobicoke General Hospital FACT Peel FAME Family Family Physician Family Services of Peel Family Transition Place Foodbank Forensic Nurse Friend Friends and Advocates General Hospital (including Emergency Room) General Hospital (Outpatient Psych. Serv.) General Hospital (Substance Abuse Inpatient) General Hospital (Substance Abuse Outpatient) Geneva Centre Geriatric Psychiatry Geriatric Psychiatry - CMHA Geriatric Psychiatry - OTN Griffin Centre Halton Health Care Services Halton Police Halton Service Resolution Halton Support Services Hamilton Psych. Hospital Hanrahan Youth Services HASP Headwaters Health Care Centre Health IM Heart House Hospices Heart Lake Secondary School Here 24 Seven Home & Community Care Home For Good Homewood Health Centre Hope 24/7 Hospital to Home Program Housing Help Group Housing Worker HPS Community Health Ambassador HPS Short Term Case Management India Rainbow Interim Place Information Only Jean Tweed Centre John Howard Society Kerry's Place Autism Services Kids Country Club Kids Pathways Peel Kinark Child and Family Services Knight's Table L-T Care Facility Landlord Legal Agencies Legal Aid Ontario Legal Services: Dufferin Legal services Mississauga Compass Legal Services Peel LHIN Links2Care Long Term Care Maple Grove Care Community Maplehurst March of Dimes Mary Centre McMaster Children's Hospital MCSS MCYS Media Mental Health and Addiction Nurses Mental Health Worker Mimico Mobile Crisis of Peel Mobile Health Clinic Mobile Outreach MTO (Ministry of Transportation) Mzac Food Bank Naloxone Kit Nexus Youth Services North Peel & Dufferin Community Legal Services Notre Dame Catholic Secondary School Nursing Home Oakville Trafalgar Memorial Hospital Obtain Housing OCI One Link Ontario Disability Support Program Ontario Federation for Cerebral Palsy Ontario Health Ontario Shores Ontario Works Open Window Hub (OWH) OPP OPP - Caledon OPP - Dufferin Orangeville Food Bank Orangeville Police Service Other Other (Unknown) Out of Region Our Place Peel Outreach Concurrent Support Outreach Intensive Housing Support PAARC Palliative Parkway Public School Partner PCCN Peace Ranch Peel Alternative School North Peel Behavioural Services Peel Children's Aid Society Peel Children's Centre Peel Children's Centre Crisis Response Peel District School Board Peel Family Shelter Peel Housing Peel Mannor LTC Peel Memorial Hospital Peel Mobile Crisis Peel Public Health Peel Regional Police Peel Seniors Peel Shelter Line Peel Wraparound Peel Youth Village peel.cioc.ca Penetanguishine PHABIS Pharmacy Police PRC - Geriatric Resource Consultants Primary Care Probation Probation and Parole - Brampton Probation and Parole - Mississauga Probation and Parole - Toronto Psychiatric Hospital Psychiatrist (Community) Psychiatrist (Private) Psychologist Public Guardian & Trustee Punjabi Commmunity Health Centre Rapport Youth and Family Services Rapport Youth Drop In Bramalea Rapport Youth Drop In Brampton Reconnect Regeneration Regeneration - ID Clinic Region of Peel Religious Leader ReLinC Retirement Home Rexdale Addiction Support Rexdale CHC Rexdale Community Support Rexdale Focus Rexdale Mental Health Counselling Roy McMurtry Youth Centre RRN (Rapid Response Nurses) Safebeds Saint Augustine Secondary School Salvation Army Salvation Army Cuthbert House School System Education Agency Self - Family/Friend Suggested Self - Poster/Brochure Self - Primary Care Suggested Self - Social Media Self - Web Search Self Senior's Centre Seniors Mental Health Outpatient and Outreach Programs Senior's Program Service Resolution Shelburne Police Service Shelters SHIP Social Service Agency Southlake Regional Health Centre Spectra - Distress Centre Spectrum Foster Care Services Inc. Speech and Language Pathologist St. Elizabeth Health Care St. Elizabeth Rehabilitation St. Joseph's Health Centre - Toronto St. Leonard's Place Peel St. Mary's Food Bank Ste. Louise Outreach Centre Peel Street Help Line Street Patrol Streetsville Care Community Taxi The Mississauga Food Bank Toronto Western Hospital Toronto's Children's Aid Society Tri-Hospital TRE-ADD Treat at Home - CANES Treat at Home - Reconnect Trillium Health Centre Trillium Health Partners Seniors Health Clinic Trillium Health Partners Seniors Mental Health Tullamore Care Community Vanier Victim Services Victorian Order of Nurses Peel Walk In Clinic Weather Alert - Cold Weather Alert - Hot Wilkinson Road Shelter Referral Source Contact Name Referral Source Address Referral Source Phone Number

Please follow the format ###-###-#### for contact numbers and please include the necessary "-"

Referral Source Fax Number

Please follow the format ###-###-#### for contact numbers and please include the necessary "-"

Referral Source Email Referral Source Professional Designation Billing Number Is this a referral from an Emergency Department Visit for Addictions or Mental Health? Choose One Yes No If yes specify Is this a referral from Mental Health Inpatient Unit? Choose One Yes No If yes specify:

Reason for Referral - Support Needed

Concerns, diagnosis, situation, symptoms, risk to others * Medications - List all current medications