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GTA Rehab Network Integrated Acute Care toInpatient Rehab & Complex Continuing Care (CCC) Referral FormThis referral form is in compliance with the Provincial Referral Standards andincludes supplemental information for referral to Rehab/CCC programs in the GTA.Insert Health Service Provider LogoPatient IdentificationReferral DestinationReferral to Rehab: (Please check one)HTSD / Regular streamLTLD/slowstreamEither (Receiving facility to determine)Referral to Complex Continuing Care (CCC) (For LTLD / slowstream rehab, select within Rehab Category above)If Faxed Include Number of Pages (Including Cover): PagesEstimated Date of Rehab/CCC Readiness: DD/MM/YYYYPatient Details and DemographicsHealth Card #:Version Code:No Health Card #:No Version Code:Surname:Province Issuing Health Card:Given Name(s):No Known Address:Home Address:City:Postal Code:Country:Province:Telephone:Alternate Telephone:No Alternate Telephone:Current Place of Residence (Complete If Different From Home Address):Date of Birth: DD/MM/YYYYGender:MFYesNoInterpreter Required:Patient Speaks/Understands English:Primary Language:EnglishFrenchOtherMarital Status:YesNoOtherPrimary Alternate Contact Person:Relationship to Patient (Please Check All Applicable Boxes):Telephone:POASDMAlternate Telephone:SpouseOtherNo Alternate Telephone:GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral FormAlternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)Page 1 of 11

GTA Rehab Network Integrated Acute Care toInpatient Rehab & Complex Continuing Care (CCC) Referral FormThis referral form is in compliance with the Provincial Referral Standards andincludes supplemental information for referral to Rehab/CCC programs in the GTA.Insert Health Service Provider LogoPatient IdentificationSecondary Alternate Contact Person:Relationship to Patient:POANone Provided:SDMTelephone:SpouseOther (Please Check All Applicable Boxes)Alternate Telephone:No Alternate Telephone:Responsibility for Payment:Insurance:OHIPInter-provincial Insurance PlanWSIBN/A:Federal GovernmentInsured/Self PayUninsured/Self PayPreferred accommodation:WardSemi privatePrivateFor CCC Only - Co-Payment Discussed With:PatientIFH (Interim Federal Health Grant)Other Payment SourcesUnknownOther (specify):OtherRehab/CCC Population Requested:ABIAmputeeBurnsCardiacChronic yRespiratory RehabSpinal CordStrokeTraumaTransplantOtherCurrent Location Name:Current Location Address:City:Province:Current Location Contact Number:Bed Offer Contact Name:Postal Code:Bed Offer Contact Number:Medical InformationPrimary Health Care Provider (e.g. MD or NP)Surname:Given Name(s):NoneAllergies:No Known AllergiesInfection Control:NoneYes --- If Yes, List Allergies:MRSAAdmission Date: DD/MM/YYYYVRECDIFFESBLTBDate of Injury/Event: DD/MM/YYYYOther (Specify):Surgery Date: DD/MM/YYYYGTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral FormAlternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)Page 2 of 11

GTA Rehab Network Integrated Acute Care toInpatient Rehab & Complex Continuing Care (CCC) Referral FormThis referral form is in compliance with the Provincial Referral Standards andincludes supplemental information for referral to Rehab/CCC programs in the GTA.Insert Health Service Provider LogoPatient IdentificationNature/Type of Injury/Event:Primary Diagnosis:Current Medical Issues:Past Medical History:Attach the following:Medication:MARLab Work:If indicated, send most recent lab work (e.g. Haemoglobin, white blood cell count, lytes, creatinine)Height:Weight:Is Patient Currently Receiving Dialysis:Location:YesNoPeritonealHemodialysis Frequency/Days:If Dialysis Centre is located off-site from rehab/CCC, indicate how patient will access Dialysis Centre:Family drivesVolunteer drivesWheel-TransOtherIs Patient Currently Receiving Chemotherapy:YesNoFrequency: Duration:Location:Is Patient Currently Receiving Radiation Therapy:YesNoFrequency: Duration:Location:Concurrent Treatment Requirements Off-Site:Prognosis:ImproveRemain StableYesDeteriorateNoDetails:Palliative Palliative Performance Scale:UnknownGTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral FormAlternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)Page 3 of 11

GTA Rehab Network Integrated Acute Care toInpatient Rehab & Complex Continuing Care (CCC) Referral FormThis referral form is in compliance with the Provincial Referral Standards andincludes supplemental information for referral to Rehab/CCC programs in the GTA.Insert Health Service Provider LogoPatient IdentificationAdvanced Medical Directives:Services Consulted:PTOTPending Investigations:YesSWSpeech and Language PathologyYesOtherNo Details:Frequency of Lab Tests: Unknown:Study Medications:NutritionNone:No Details:Respiratory Care RequirementsDoes the Patient Have Respiratory Care Requirements?Supplemental Oxygen:YesNoYesVentilator:No -- If No, Skip to Next SectionYesNoTarget 02 Sat %Intermittent Oxygen L/min02 at rest L/min02 at exercise L/minConstant Oxygen L/minSpecial Oxygen Equipment/Human Resources required? (e.g. rebreather, Optiflow, specialized resources of Respiratory Therapist):NoYes (if Yes, please specify):Breath oPatient Owned:Bi-PAP:YesNoRescue Rate:YesCufflessYesYesNoType:Size:NoNoPatient Owned:YesNoAdditional Comments:IV TherapyIV in Use?YesNo -- If No, Skip to Next SectionGTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral FormAlternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)Page 4 of 11

GTA Rehab Network Integrated Acute Care toInpatient Rehab & Complex Continuing Care (CCC) Referral FormThis referral form is in compliance with the Provincial Referral Standards andincludes supplemental information for referral to Rehab/CCC programs in the GTA.Insert Health Service Provider LogoIV Therapy:YesPatient IdentificationNoCentral Line:YesNoPICC Line :YesNoName of IV Medication:Hearing/VisionHearing:Intact, can hear routine conversationIntact, with hearing aidReduced hearingCompletely impairedAmerican Sign LanguageVision:IntactIntact with visual aidVisual field deficitDouble visionCompletely impairedSwallowing and NutritionSwallowing Deficit:YesNoSwallowing Assessment Completed?:YesNoType of Swallowing Deficit Including any Additional Details:TPN:Yes (If Yes, Include Prescription With Referral)Enteral Feeding:Diet:YesRegularNoNoTube Type:KosherDiabeticRenalSpecify Formula Type & Rate of Feeds:Low SodiumOther (specify):FallsDoes Patient Have a History of Falls?If yes, specify:Yeshome/communityHistory & Frequency:FrequentReason for most recent fall(s):BalanceVisionNo -- If No, Skip to Next eased insight/judgmentUnknownOther (list):Skin ConditionSurgical Wounds and/or Other Wounds Ulcers?1. Location:YesNo -- If No, Skip to Next SectionStage:GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral FormAlternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)Page 5 of 11

GTA Rehab Network Integrated Acute Care toInpatient Rehab & Complex Continuing Care (CCC) Referral FormThis referral form is in compliance with the Provincial Referral Standards andincludes supplemental information for referral to Rehab/CCC programs in the GTA.Insert Health Service Provider LogoPatient IdentificationDressing Type:(e.g. Negative Pressure Wound Therapy or VAC)Time to Complete Dressing:Frequency:Less Than 30 MinutesGreater Than 30 Minutes2. Location:Dressing Type:(e.g. Negative Pressure Wound Therapy or VAC)Time to Complete Dressing:Stage:Frequency:Less Than 30 MinutesGreater Than 30 Minutes3. Location:Dressing Type:(e.g. Negative Pressure Wound Therapy or VAC)Time to Complete Dressing:Stage:Frequency:Less Than 30 MinutesGreater Than 30 Minutes* If additional wounds exist, add supplementary information on a separate sheet of paper.ContinenceIs Patient Continent?YesNo -- If Yes, Skip to Next SectionBladder Continent:YesNoIf No:Occasional IncontinenceIncontinentBowel Continent:YesNoIf No:Occasional IncontinenceIncontinentOstomy:N/AYes Type/brand and care/products requiredAbility to care for ostomy:IndependentTotal careRequires supervisionPain Care RequirementsDoes the Patient Have a Pain Management Strategy?YesControlled With Oral Analgesics:YesNoMedication Pump:YesNoMethadone:YesNoEpidural:YesNoHas a Pain Plan of Care Been Started:YesNoNo -- If No, Skip to Next SectionCommunicationDoes the Patient Have a Communication Impairment?YesNo -- If No, Skip to Next SectionGTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral FormAlternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)Page 6 of 11

GTA Rehab Network Integrated Acute Care toInpatient Rehab & Complex Continuing Care (CCC) Referral FormThis referral form is in compliance with the Provincial Referral Standards andincludes supplemental information for referral to Rehab/CCC programs in the GTA.Insert Health Service Provider LogoPatient IdentificationCommunication Impairment Description:CognitionCognitive Impairment:YesNoUnable to Assess -- If No or Unable to Assess, Skip to Next SectionDetails on Cognitive Deficits:Has the Patient Shown the Ability to Learn and Retain Information:Cognitive Status (CompleteTable Below)Not ion(specify):Able to follow instructions(specify):Memory (short term)(specify):Memory (long Frustration Tolerance (ABI only)(specify):Other(specify):MMSE Score:MoCA Score:orNo -- If No, Details:If did not/unable to complete, please explain:Rancho Los Amigos Cognitive Scale at present: (ABI only):Delirium:YesNo -- If Yes, Cause/Details:GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral FormAlternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)Page 7 of 11

GTA Rehab Network Integrated Acute Care toInpatient Rehab & Complex Continuing Care (CCC) Referral FormThis referral form is in compliance with the Provincial Referral Standards andincludes supplemental information for referral to Rehab/CCC programs in the GTA.Insert Health Service Provider LogoHistory of Diagnosed Dementia:Patient IdentificationYesNoBehaviourAre There Behavioural Issues?YesNo -- If No, Skip to Next SectionDoes the Patient Have a Behaviour Management Strategy:Behaviour:YesNoNeed for Constant ObservationVerbal AggressionPhysical AggressionSundowningExit-SeekingResisting CareAgitationWanderingOtherRestraints -- If Yes, Type/Frequency Details :Level of Security:Non-Secure UnitSecure UnitWander GuardOne-to-oneSocial HistoryDischarge Destination:Multi-StoreyBungalowRetirement Home (Name):ApartmentLTCAccommodation Barriers:Smoking:YesUnknownNo Details:Alcohol and/or Drug Use:YesNoDetails:Previous Community Supports:YesNoDetails:Discharge Planning Post Hospitalization Addressed:Discharge Plan Discussed With Patient/SDM:YesYesNo Details:NoCurrent Functional StatusPatient Goals (Please Indicate Specific, Measurable Goals):Participation Level:(Specify): On average, patient is able to participate in therapy sessions / day, times / week for minutes / sessionSitting Tolerance:More Than 2 Hours DailyTransfers:Independent1-2 Hours DailySupervisionAssist x1Less Than 1 Hour DailyAssist x2Has not Been UpMechanical LiftGTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral FormAlternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)Page 8 of 11