Intake information

The following information is collected at the time of intake:

  1. Referring Person's Name, Profession, Affiliation, Phone Number
  2. Primary care provider or Case Manager
  3. Patient's Family Name and First Name
  4. Medicare Number, Expiry Date
  5. Patient's Prescription Coverage
  6. Gender
  7. Marital Status
  8. Date of Birth, Age
  9. Patient's Address & telephone number
  10. Patient's physician
  11. Country of Origin, Date of Arrival
  12. Name of children, their ages, dates of birth, occupation/grade
  13. Immigration Status
  14. Mother Tongue
  15. Other languages spoken
  16. Religion
  17. Ethnicity (as defined by patient)
  18. Education
  19. Occupation, Employment Status
  20. Need for Interpreter, Preferred language
  21. Reasons for Consultation ( specification of the cultural problem for which you are seeking consultation; e.g. clarify diagnosis, choice of treatment or therapeutic strategy, difficulty with clinical communication or treatment compliance
  22. What do you expect the Cultural Consultation Service to provide you?
  23. How did you come to know about our service?
Back to top