Forensic Assessment and Community Services (FACS) Referral
Please complete and return by Fax to 780.426.7272, by email facs@ahs.ca, or by mail to
10225 - 106 Street, Edmonton, AB T5J 1H5
Have client sign Consent to Disclose Health Information (on reverse)
Services Requested
________________________________________________________________________________________
Client
First Name Last Name Middle Name Alias
Date of Birth (yyyy-Mon-dd) Gender PHN
Male Female
Address (including Apt #) City Postal Code
Home Phone Cell Work Phone
Referral Source
Referred by Phone Fax
Name of Agency
Address Postal Code
Date of Referral (yyyy-Mon-dd) Court Date (yyyy-Mon-dd, if applicable) Date Report Required (yyyy-Mon-dd)
Legal Information
Current Charge(s) /Offence(s)
Legal Status
Conditional Sentence Pre-Sentence Voluntary
Probation Peace Bond Serving Prisoner
Other (specify) ___________________________________________________________________________
Treatment Condition
Date Sentenced (yyyy-Mon-dd) Disposition
Sentence Expiry Date (yyyy-Mon-dd) Custody Expiry Date (yyyy-Mon-dd) Probation Expiry Date (yyyy-Mon-dd)
Clinical Information
Problem Behaviour and/or Referral Question
Does client have a serious /drug/alcohol problem? No Yes
If yes, has it been addressed? No Yes
Relevant Background Information (Family, job, past history)
Required Attachments
Court Order/Probation Order Criminal Record OR No Previous Record
Circumstances of Offence Probation PSR Report
Can we contact the client directly about the appointment? No Yes
Safety Issues/Special Concerns N/A
Other Individuals/Agencies Presently Involved Phone Fax
Appointments (specify) Date (yyyy-Mon-dd) Time (hh:mm) FACS File (if applicable)
FAC 3(2018-05) Side A
Consent to Disclose Health Information
Health Information Act
The patient/client or his/her authorized representative must complete this form before Alberta Health Services (AHS) will
disclose the patient’s/client’s health information to someone else (unless Alberta’s Health Information Act authorizes disclosure
without consent).
Section A: Patient/Client Information
Patient/Client Name
Date of Birth (yyyy-Mon-dd) Personal Health Number
Section B: What health information do you want disclosed?
Please provide details about the health information you want disclosed, such as the name of the AHS location/facility that
provided the health service and the time period of the records.
Section C: What individual/organization is the patient’s/client’s health information being disclosed to?
Name of Individual/Organization Phone
Address City/Town Province Postal Code
Section D: What is the purpose for disclosure?
Please provide the reason why you want to disclose the health information (required).
Section E: Authorized Representative (required when asking for health information on behalf of another person)
If you are signing on behalf of the patient/client named in section A, please choose one of the options below and provide a
copy of supporting documents.
I, ____________________________, am
(insert representative name)
the parent or legally appointed guardian of the patient/client who is under 18 years of age and who is not a
mature minor in relation to their health information.
the guardian or trustee appointed for the adult patient/client under the Adult Guardianship and Trusteeship Act
exercising my powers or duties as their guardian or trustee.
the patient/client’s agent named in an activated Personal Directive under the Personal Directives Act exercising my
authority set out in the Personal Directive.
the personal representative of a deceased patient/client appointed by the patient/client’s will or by the Court,
administering the patient/client’s estate.
the patient’s named attorney in a Power of Attorney currently in effect exercising my powers and duties conferred by
the Power of Attorney.
the patient/client’s nearest relative selected in accordance with the Mental Health Act carrying out my obligations as
the nearest relative.
the patient/client’s specic decision maker, supportive decision maker, or co-decision maker, authorized in
accordance with the Adult Guardianship and Trusteeship Act carrying out the related duties.
a person with written authorization from the patient/client to act on their behalf.
Section F: Consent for Disclosure
I authorize Alberta Health Services to disclose the patient/client’s health information described above to the individual or
organization(s) identied above. I understand why I have been asked to disclose my health information and I am aware of the
risks and benets of consenting or refusing to consent. I understand I may revoke this consent in writing at any time.
Date consent is effective (yyyy-Mon-dd) Expiry date (yyyy-Mon-dd)(valid for 2 years if no date provided)
Name of person giving consent Phone Email
Signature Date (yyyy-Mon-dd)
Information on this form and the supporting documentation are collected under the authorization of sections 20 - 22 of the Health
Information Act for the purpose of responding to your request and will be led on the patient/client record. If you have questions about the
collection and use of any information on this form, contact the Disclosure Help Line at 1.855.312.2265.
18028(Rev2017-07)
FAC 03(2018-05) Side B
