New Outlook Referral Form
All services with New Outlook are voluntary in nature. Our programs seek to fill the gaps that currently exist for youth between child and adult
mental health services within the community. Our aim is to support and encourage youth diagnosed with a serious mental illness, instil a sense
of hope and foster independence. Our focus is on mental health wellness and recovery.
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Community Support and Intervention Program
CSI offers short-term voluntary intensive case management to young adults aged 16-24 who are involved in the criminal
justice system (or are at high risk) and who have a serious mental illness. The support worker will connect clients to crisis
services, arrange psychiatric assessments, links to housing, income support, social and vocational supports, and long term
mental health services.
Eligibility: Must be 16-24 years old, reside in Toronto, and have a diagnosis of a serious mental illness (when the diagnosis
is not clear, CSI can arrange a psychiatric assessment) and have involvement in the criminal justice system or be at high
risk of involvement.
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Community Support Program
The CSP offers long-term case management to young people with serious mental illness (psychosis, affective disorders).
Through building relationships with our clients, goals are developed that are individualized, flexible and comprehensive. A
community support worker collaborates with clients to develop a rehabilitation plan.
Eligibility: Must be 16-24 years old, reside in Toronto and the primary diagnosis must be an Axis 1 psychiatric disorder.
Functional disorders resulting from other issues such as developmental delays or substance abuse must clearly be
secondary to the psychiatric diagnosis.
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Day Program
The Day Program provides support to young people with serious mental illness (psychosis, affective disorders). The
mainstay of the program is life and social skills training, recreation as well as academic studies in a structured and
supportive environment. The program focuses on helping young people to understand and manage their illness. An on-site
teacher provides an innovative special education program that allows clients to earn high school credits.
Eligibility: Must be 16-24 years old, reside in Toronto and have a diagnosis of a serious mental illness. Client must have a
diagnosis of a psychotic illness, affective disorder, and no active substance abuse issues. Client must experience significant
problems in social and life skill functioning due to the mental illness and must have an active case manager/community
support worker.
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Early Intervention Program
This program offers support to young people who are experiencing a first episode psychosis and/or symptoms that are
consistent with the onset of psychosis. We assist young people aged 13-24 and their families in connecting to mental health
services. Through counselling, support, skill building and advocacy, this program helps young people navigate the mental
health system.
Eligibility: Must be between the ages of 13-24 and live in Toronto. The primary consideration must be related to a first
episode of psychosis and/or symptoms that are consistent with the onset of psychosis and a recent marked decline in
cognitive and/or social functioning. Client must have less than one year clinical involvement.
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Youth Hostel Outreach Program
YHOP meets the needs of young people with serious mental illness who use the shelter system. It supports hard to reach
youth who are unlikely to seek out traditional mental health services. YHOP offers psychiatric consultation and assessment
as needed and links to mental health services. The goals are to reduce the risk of homelessness and connect youth with
much needed services.
Eligibility: Must be 16-24 years old and reside in a shelter environment. Youth must present symptoms of psychosis and be
experiencing serious mental health issues. No formal diagnosis is necessary and must be without formal mental health
support.
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NEW OUTLOOK REFERRAL FORM
Contact: 416-924-2100
Fax: 416-924-2930
IMPORTANT: Please ensure the following prior to forwarding the referral:
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Client is aware of the referral
Client Consent Form has been signed and dated
Consent Form is included with this referral(referral will not be processed without consent)
All supporting documentation should be included with this referral
Specify Program:
 Community Support and Intervention
 Day Program
 Youth Hostel Outreach Program
 Community Support Program
 Early Intervention for Psychosis
Reason for Referral: ( all that apply)
 Case management
 Transitional support/planning
 MH – Recovery & Wellness Planning
 Psychosocial supports (individual & family)
 Educational/Vocational Support
 MH/Legal Support
Referral Date: (DD/MM/YY)
Referral Source Information
Name:
Agency:
Address:
Address
City
Postal Code
Telephone:
Extension:
Cellular (optional):
Email: ____________
______
Client Information
Last Name:
First Name:
Address:
Number
Street Name
City
Postal Code
Home Tel. Number:
Other Contact Number:
Cellular:
Email: __________________
Date of Birth (DD/MM/YY):
Age:
Gender:  Male  Female  Other
Cultural Background:
Birthplace:
Language(s):
Immigration / Citizenship / Status:
S.I.N.:
______
Health Card #:
Optional
Education/Employment:
History of Homelessness:
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Emergency Contact Information
1. Name:
Relation:
Address:
Number
Street Name
Home Tel. Number:
City
Postal Code
Cellular Number:
Bus. Tel. Number:
Extension:
Email: ________________________
2. Name:
________________Relation:
Address:
Number
Street Name
Home Tel. Number:
City
Postal Code
Cellular Number:
Bus. Tel. Number:
Extension:
Email: ________________________
Client Contacts
Psychiatrist:
Address:
Telephone Number:
Frequency of contact:_______________________ Length of contact:
Primary Diagnosis:
__________________Date:
By Whom:
Concurrent Disorder?
______
Yes
No
Comments:
Tel #: _______________
Developmental Delay?
Yes
No
Comments:
Other mental health diagnosis:
General Practitioner:
Address:
Telephone Number:
Other medical concerns: (include any relevant past or current conditions, allergies and related medications, treatments,
and/or physicians involved)
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Current Presenting Issues: (Within the past 6 months)
Symptoms ( all that apply):
 Hearing Voices
 Delusions (firm false beliefs)
 Agitation/Restlessness
 Anxiety


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Paranoia
Isolates
Depression
Self-Harming
 Talking to themselves
 Intensified mood swings
 Sleep Disturbances

 Homicidal Ideation
 Suicidal Ideation
 Ideas of grandeur

Other areas of concern:
___________
Medications:
Name
Dosage & Frequency
Administered By
Compliance
Prescribed by:
_
Psychiatric History
1. First Psychiatric Admission (place, date, duration):
_
_
_
2. List the two most recent admissions:
Hospital
History of Trauma
Yes
How has this been addressed?
Dates of Stay
Reason for Hospitalization
Discharge Diagnosis
No
_
_
_
History of aggression: Yes
No
 Toward self
 Toward others
 Toward property
 Sexual Assault
 Other
_______________________________________________________________________________________
______ _______________________________________________________________
History of substance abuse:
How has this been addressed?
_
_
_
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List other agencies/services the client is or has been involved with, including dates of involvement.
(i.e. Housing, educational, vocational) with contact person and telephone number:
Agency
Contact Person
Telephone number
Dates of Involvement
Lawyer:
Address:
Telephone Number:
Provide legal history/pending charges:
Signature of Referral Source
Date
*Attach any relevant assessments, summaries or documents which may support this referral
Office Use Only
Client ID number:
Date Received:
Date Scanned:
Follow-up
Day Program: Site visit date: __________________________
Intake meeting: date _________________________________
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NEW OUTLOOK REFERRAL FORM
Contact: 416-924-2100
Fax: 416-924-2930
FAX TRANSMISSION
TO:
TYPE RECIPIENT NAME
DATE:
7/31/2017 11:55 PM
FAX No.:
TYPE RECIPIENT FAX NUMBER
SUBJECT:
TYPE FAX SUBJECT
FROM:
TYPE YOUR NAME
PAGES (Inc. Cover): TYPE #
Please ensure that you include the following as part of the New Outlook Referral Package:
 Referral Form
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Authorization for Disclosure, Transmittal or Examination of Confidential Information
Psychiatric reports
Hospital Discharge Summary reports
Educational reports
Other:
Any additional information:
CAUTION: This transmission may contain confidential information
intended for the specified recipient only.
Transmission, access, use and disclosure of the contents or attachments herein are governed by various Acts of Legislation
including: the Youth Criminal Justice Act, the (Ontario) Child and Family Services Act, the Personal Health Information
Protection Act and the Freedom of Information and Protection of Privacy Act. If you have received this transmission in error,
please notify us immediately by e-mail [email protected] or by telephone (416-924-2100) and delete the original message.
Contents of this transmission do not necessarily reflect the official views or policies of Central Toronto Youth Services.
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