Community Outreach and Assessment Support Team Clinician Referral (Edmonton Zone) Form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Demographical Information section. Enter the name of the person, today’s date, provincial health care number, date of birth, address, and contact details. Ensure all fields are completed accurately.
3. In the Referring Source section, provide your name, phone number, email address, and signature along with the date. This identifies you as the referring health professional.
4. For the Reason for Referral section, check all applicable boxes that describe why you are making this referral. Be specific about primary issues and concerns.
5. Complete the Background Information section by detailing medical history and any developmental or mental health concerns. This information is crucial for understanding the patient's needs.
6. List all relevant medications in the Medications section to ensure comprehensive care.
7. Finally, confirm consent and decision-making ability by checking appropriate options in that section. Make sure to indicate if guardianship orders are applicable.

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