Please check this box, if you are requesting mental health services for yourself Please check this box, if you are requesting mental health services for someone else If you are requesting services for someone else, have you informed the person that they will be referred to our services? Yes No Referral Requested by:* Date of Referral MM slash DD slash YYYY Name of Organization:* Phone*Ext. Email* ConsentThis program is a partnership between Ottawa Newcomer Health Centre and Jewish Family Services of Ottawa. Employees at either or both sites may be involved in providing care.Is it okay to receive services from either or both agencies?* Yes No If referral is accepted, is it okay to save the information below in our client record system?* Yes No DetailsName: First Last Date of Birth (YYYY/MM/DD):* Address:* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone (home):Phone (mobile):Preferred Language of Service:* Best way to leave a message:* Message can be left on the home phone Message can be left on the mobile phone Reason for referral (you may attach additional documents)Please provide the reason for referralPlease attach any relevant documents in one of the following formats – MS Word (.doc or .docx), PDF (.pdf), Image (.jpg, .png, .gif)FileAccepted file types: doc, docx, jpg, gif, png, pdf, Max. file size: 32 MB.Use the Subjective Units of Distress Scale below to indicate the current level of distress/anxiety.Please select ONE number only.Assessment of usual distress level* 100 – Highest anxiety/distress that you have ever felt. 90 – Extremely anxious/distressed. 80 – Very anxious/distressed; can’t concentrate. Physiological signs present. 70 – Quite anxious/distressed; interfering with functioning. Physiological signs may be present. 60 – Moderate-to-strong anxiety or distress. 50 – Moderate anxiety/distress; uncomfortable, but can continue to function. 40 – Mild-to-moderate anxiety or distress. 30 – Mild anxiety/distress; no interference with functioning. 20 – Minimal anxiety/distress. 10 – Alert and awake; concentrating well. 0 – No distress; totally relaxed. Internal Use OnlyPriority: Existing Client: Yes No Chart #: Δ
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