PREVENTION & EARLY INTERVENTION PROGRAM FOR PSYCHOSES (PEPP) REFERRAL FORM

Please review eligibility criteria below prior to completing the referral.

Physicians and Community Providers: Please complete all sections of this form.

Family, Friends or Self Referral; Please complete as much information as you have access to
(Contact info and symptom description are mandatory).

- Between 16 & 35 years
- Life time antipsychotic use less than 30 days
- Symptoms of first episode, psychosis
- No developmental delay
- No history of brain injury, epilepsy or other brain disorder.
- No Methamphetamine Use in last 3 months.

Date

PIN #

HCN #

Name

Date of Birth

Address

Phone Number

Other Contact Details

Where does the client Reside and with whom?

Is housing stable?

Risk of homelessness?

Homeless?

Source of Referral

Other Source of Referral

Referral Source Contact

Has client been informed of PEPP referral?

Does client have a Family Doctor/Nurse Practitioner?

Please provide name and contact information

Attachment Note

If referral source is Physician or Agency a consult note/relevant information MUST be attached to process referral
You may upload up to three files below.

Maximum 3 files.
8 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Sources of Support

Family

Community Agency

Physician

Other

Other Support

Family Member Contact Information (Name, Telephone)

Community Agency Involvement (Names, Telephone)

Is client attending school?

Highschool

Fanshawe

UWO

Other

Other School

Is client working?

Client's Primary Source of Income

Please describe

Please describe in as much detail as possible the symptoms the client is experiencing. Please consider the following;

Hearing voices, seeing odd things that are not visible to others, feeling odd sensation on or in body. (Hallucinations)
Having unusual ideas that are not grounded in reality. (Delusions)
Believing that they can control others thoughts or that their thoughts are being controlled. (Thought Disorder)
Unrealistic paranoia such as worrying about being spied on, conspired against or poisoned. (Paranoia)
Uncharacteristic changes in their mood.
Bizarre or drastic changes in their behavior.
Significant changes in sleeping patterns. (Insomnia)
Changes in social habits (isolation, change in peer group).

Family Psychiatric History

Please specify

Substance Use History

Please specify substance, frequency of use, method of use, how long they have been using

Psychotropic Medication History

Please specify

History of Trauma (Abuse, violence, disaster)

Please specify

Previous Emergency Dept Visits for Mental Health

History of violence, criminal charges or incarceration

Please specify

Contact Info

Tel: 519-685-8500 ext. 71680 Fax: (519)667-6657