The following information is collected at the time of intake:
- Referring Person's Name, Profession, Affiliation, Phone Number
- Primary care provider or Case Manager
- Patient's Family Name and First Name
- Medicare Number, Expiry Date
- Patient's Prescription Coverage
- Gender
- Marital Status
- Date of Birth, Age
- Patient's Address & telephone number
- Patient's physician
- Country of Origin, Date of Arrival
- Name of children, their ages, dates of birth, occupation/grade
- Immigration Status
- Mother Tongue
- Other languages spoken
- Religion
- Ethnicity (as defined by patient)
- Education
- Occupation, Employment Status
- Need for Interpreter, Preferred language
- 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
- What do you expect the Cultural Consultation Service to provide you?
- How did you come to know about our service?
