Keystone Child, Youth & Family Services
1793 3rd Avenue West
Owen Sound  Ontario  N4K 6Y2


Phone: (519) 371-4773,
Fax: (519) 371-6397,
Email: keystone@keystonebrucegrey.com
Referral Type:
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Referral:
02 SUSD Hospital or Crisis Referral ID
Date: 2026-10-05 20:45
Status: Draft
Attachment(s):
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HOSPITAL OR CRISIS REFERRAL FORM to INTENSIVE TREATMENT PROGRAM

Use this form for referrals from a hospital or crisis service when step-up or step-down support is being considered. It may be completed by a hospital social worker, child and youth worker, nurse, psychiatrist, crisis clinician, nurse practitioner or most responsible clinician. Please provide concise, current information needed to help determine whether Keystone's voluntary, non-secure SUSD service can safely support the youth's transition from hospital or crisis care.
 
Hide/ShowYOUTH INFORMATION
Legal First Name
Legal Last Name
Preferred Name
Date Of Birth
Select Date Clear Date
Health Card
Telephone
Client Street Address
Address Line 1
Address Line 2
City
Postal Code
Province
Country
 
Parent / guardian
Telephone
Placing Agency
if applicable
Legal / custody information
Hide/ShowREFERRAL AND DISCHARGE INFORMATION
Referral Source
Hospital / crisis team
Referring Practioner/ Clinician and Role
Telephone
Secure email
Referral date/time
Select Date Clear Date
Proposed transition date/time
Select Date Clear Date
Hide/ShowCONSENT AND INFORMATION SHARING
Youth aware of referral to Keystone
*please upload Consent for Obtain/Release Information
Yes
No
Parent/guardian/substitute decision-maker aware
Yes
No
Not applicable
Hide/ShowCURRENT CLINICAL STATUS
Reason for hospital/crisis involvement and current presentation
Most Responsible Physician / Nurse Practioner
Primary diagnoses or working formulation
Why is SUSD being requested now?
Youth and family goals for SUSD
Hide/ShowIMMEDIATE SAFETY AND SUPERVISION
Suicide / self-harm
Current status
None
Historical
Current
Recommended support/supervision during transition
Aggression / violence
Current status
None
Historical
Current
Recommended support/supervision during transition
Elopement / missing
Current status
None
Historical
Current
Recommended support/supervision during transition
Psychosis / severe disorganization
Current status
None
Historical
Current
Recommended support/supervision during transition
Substance use / withdrawal risk
Current status
None
Historical
Current
Recommended support/supervision during transition
Other medical or safety concern
Current status
None
Historical
Current
Recommended support/supervision during transition
 
Current observation / supervision level
Indicators of activation, warning signs and strategies that help
Emergency escalation or return-to-hospital instructions
Hide/ShowTRANSITION REQUIREMENTS
Follow-up appointments and responsible provider
Information attached with referral *please upload
Discharge summary
Medication record
Safety/Coping plan
Medical information
Legal/custody information
Consent for Obtain/Release Information
Other
If Other selected, please describe
Hide/ShowCLINICAL CONFIRMATION

To the best of my knowledge, the youth is appropriate for consideration for transition to Keystone's voluntary, non-secure Step Up Step Down program. Relevant medical, psychiatric, safety, monitoring and return-to-hospital instructions are documented above.

Name
Signature / electronic signature
Date
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