Client name:		      DOB:Click or tap to enter a date.                    	OHIP #:      
Address: 
Date of intake assessment: Click or tap to enter a date.     	  Intake clinician: Jordan Adams	

☐ OSP consent
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☐ Electronic communication consent	☐Confidentiality reviewed

☐ Referent sharing (letter)
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☐ PCP sharing (letter)
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☐ Demographic information

	OSP REFERRAL INFORMATION
Date of referral: Click or tap to enter a date.			Referent: 
Main problem descriptor(s) on referral: 
☐ Depression and low mood		☐ Generalized anxiety and worry		☐ Specific fears
☐ Social anxiety and performance fears	☐ Health anxiety				☐ Posttraumatic stress
☐ Obsessive-compulsive concerns		☐ Unexpected panic attacks and agoraphobic fears
☐ Other anxiety and stress related problems
Additional information or resources provided with referral:





ELIGIBILITY AND SCREENING INFORMATION
Any exclusionary considerations/clarifications identified?: ☐No		 ☐ Yes:	
☐ Active mania within the last year	☐Intense changes in emotion within the same day	☐Recent death of someone close to them	☐Active psychosis within the last year	☐Active self-harm

☐Disruptive misuse of alcohol or substances within 6 months	☐Suicide attempt within 6 months	☐Disruptive eating/body image behaviours	☐Significant cognitive functioning concerns	☐Other:

•	☐ Yes ☐ No – Is client engaged in similar services elsewhere? 
NARRATIVE AND REASON FOR REFERRAL TO OSP
Client’s Reason for referral (client’s current concerns): 
Client goal from participating in therapy program:
Mental health history: ☐No		 ☐ Yes:	
Previous counselling/therapy: ☐No		 ☐ Yes:	
CLINICAL INTAKE & TRIAGE ASSESSMENT INFORMATION
PHQ-9 score: Choose an item. out of 27 - Choose an item.		
GAD-7 score: Choose an item. out of 21 - Choose an item.
Concerns about starting the program: ☐No 	☐ Yes:
Circumstances to consider regarding client’s participation: ☐No		 ☐ Yes:		
INFORMATION ABOUT MAIN PROBLEM DESCRIPTOR FOR TREATMENT
	
ADDITIONAL PROBLEM DESCRIPTOR(S) INFORMATION


RISK REPORT/ASSESSMENT
☐ No risk
☐ Low risk
☐ Moderate Risk
☐High Risk
☐Self-harming behaviours

☐ Previous attempt
☐Crisis resources shared	☐ Suicide risk MBC tool	☐ Safety plan developed (attach separate report)   	☐ Unwilling to contract to safety/plan –psychiatry	          requested
Additional risk assessment information: 
TRIAGE DECISION
Eligibility decision: ☐Yes – Eligible for OSP   ☐No – Ineligible
Main problem descriptor for treatment: Choose an item.
Service decision:
☐BounceBack   
☐iCBT - MindBeacon
☐iCBT- Tranquility
☐CAB  

☐Individual therapy
☐Group therapy
☐Closed– Service navigation 	☐Closed – no service navigation required
REASON FOR TRIAGE DECISION
☐Main problem descriptor alignment		☐Appropriateness of service     	☐Client preference
☐Client availability		☐Client ability 			☐Severity of symptoms
☐Service availability in region		☐Technology considerations 	☐Child care needs
☐Client education/reading level		☐History of suicide		☐Transportation needs ☐Other – none of the above

Additional notes for triage decision: 

INTAKE FOLLOW-UP STEPS
Submit client information to: 
☐ BounceBack
☐ Clinician-Assisted Bibliotherapy (CAB)
☐  MindBeacon iCBT
☐ Tranquility iCBT
☐ Individual therapy waitlist
☐ Other
Resources provided to client?: ☐No		 ☐ Yes:	


Can you make suggestions to change or add to the above intake document