Referring provider form

Psychiatry Referral

Standardized referral form for psychiatric consultation with Dr. S. Rasyidah A. Halim. The form is designed to be viewed on a computer. Fields marked * are required.

Patient Information

Surname *

First name *

Date of birth *

Gender

MaleFemaleOther

Health card # (province · number · version) *

Mobile # *

Home #

Business #

Email *

Address line 1

Address line 2

City

Province

Postal code

Referral Details — Triage

Referrals are considered routine by default. Mark urgent only when the patient needs urgent care.

Clinical Question / Goals of Referral

Describe relevant history, management, investigations, or expectations of the referral.

Brief description *

Cumulative Patient Profile (CPP)

Delete any sensitive information you do not intend to share from the CPP.

CPP attached separately (hide the fields below)

Current problem list

Past medical history

Current medications

Family history

Allergies

Supporting Documentation

Attach supporting documents (consult reports, discharge summaries, labs, diagnostic investigations, PHQ-9 / GAD-7 or other patient-reported scales) below, or email them to info@mindhealth.one referencing the patient's name and date of birth.

Attachments (up to 10 files, 10.0 MB per file, 20.0 MB total)

Click to add filesAllowed: PDF, DOC/DOCX, RTF, TXT, CSV, XLS/XLSX, JPG, PNG, GIF, WEBP, HEIC, TIFF

Notes about attachments (optional)

Referrer's Information

Name *

Address

City

Province

Postal code

Phone *

Fax *

Billing # *

Professional ID *

Signed *

Role

This is the Primary Care Provider

Review your entries in the preview before sending. Submissions are emailed securely to the clinic at info@mindhealth.one.