FEI YUE COMMUNITY SERVICES

COMMUNITY MENTAL HEALTH (COMIT)

REFERRAL FORM

Note: Please email completed form to COMIT@fycs.org or call our general line at 6661 9488 should you have any further query
about your referral.

SECTION 1: REFERRAL DETAILS

Agency Name:       Date of Referral:      

Name of Referring Staff:       Designation:      

Tel No:       Email:      

SECTION 2: PERSONAL DATA PROTECTION ACT

Client has consented to this referral and agreed to the disclosure of the enclosed information to the
relevant agencies/service providers to facilitate the referral.

Name of consented client: _______________________________

SECTION 3: CRITERIA FOR REFERRAL

COMIT
The COMmunity Intervention Team (COMIT) is embedded in the community to provide holistic
services for clients with mental health needs and their caregivers so that they can be integrated
and remain resilient in the community. The mental health professional team provides psycho-
social therapeutic intervention for clients with mental health needs and supports their caregivers
in coping with caregiving for their loved ones.

Criteria for Referral: Singaporean and Permanent Residents

Age 16 years old and above
Address of residency falls within the following GE2020 Electoral Map:
Brickland/ Bukit Gombak/ Choa Chu Kang/ Keat Hong/ Limbang/ Taman Jurong/
Yew Tee
Please input the postal code in the link below to check:
GE2020.Electoral.Map

Internal Referral from Fei Yue

(Please note: Client must be residing within our service boundary, which include all 5 FSCs
and AIC service boundary. Refer to GE2020 Electoral Map)

Required Service(s): Counselling/Psychotherapy

Mental Health Screening
Caregiver Support

SECTION 4: PERSONAL PARTICULARS OF CLIENT

Name:       NRIC:      

Gender: Male Female Date of       /       /      Age:      

Birth: (dd/mm/yy)

Copyright @ 2021 Fei Yue Community Services

Updated: 8 Oct 2021
 FEI YUE COMMUNITY SERVICES
COMMUNITY MENTAL HEALTH (COMIT)
REFERRAL FORM

SECTION 4: PERSONAL PARTICULARS OF CLIENT

Address:       Postal Code:      

Contact No: Home:       Mobile:       Office:      

Race: Chinese Eurasian Citizenship: Singaporean

Malay Others, please specify:       Singapore PR
Indian

SECTION 4: PERSONAL PARTICULARS OF CLIENT (continue)

Marital Status: Single Married Separated
Widowed Cohabited Divorced

Religion: Buddhism Catholic Christian

Hindu Islam Taosim
Others:      

Language English Hakka Cantonese

Spoken: Mandarin Hokkien Teochew
Malay Hainanese Others:      
Tamil

Housing Type: HDB 1 room HDB 2 room HDB 3 room

HDB 4 room HDB 5 room Studio Apartment
Landed Property Maisonette Private Property
Others:      

Housing Lodging:       Purchased/Owned Rental HDB/Private(*)

Ownership:

Employment Full Time Part Time Unemployed

Status: Unknown Retired Student
Others:      

Current Living Family Friends Spouse Alone Others:      

Arrangement:

Emergency Contact:
Name:       Relationship:       Contact No.:      

*delete where applicable

SECTION 5: CLINICAL INFORMATION OF CLIENT

Copyright @ 2021 Fei Yue Community Services

Updated: 8 Oct 2021
 FEI YUE COMMUNITY SERVICES
COMMUNITY MENTAL HEALTH (COMIT)
REFERRAL FORM

Psychiatric Diagnosis:
Anxiety Disorder Schizophrenia
Obsessive Compulsive Disorder Mild Cognitive Impairment
Depressive Disorder Alzheimer’s Disease/ Vascular Dementia/
Bipolar Disorder Lewy Body Dementia (*)
Others (including undiagnosed mental health conditions), please specify:      

Year of diagnosis:      

On medication: No Yes, please indicate medication prescribed:      

Currently followed up at (name of institution):      

Name of doctor:      

Telephone:      

Other Medical conditions:      

On medication: No Yes, please indicate medication prescribed:      

Reason(s) for referral (Please include presentation, current and past mental health concerns, current risk of
harm to self and others, and other risk factors):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Client’s history of suicide ideation(s)/attempt(s):

No
Yes, please elaborate: (including frequency, when, methods, protective factors):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Client’s history of violent behaviour:

No
Yes, please elaborate: (include lethality, type of violence, protective factor):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

SECTION 6: OTHER RELEVANT INFORMATION

Copyright @ 2021 Fei Yue Community Services

Updated: 8 Oct 2021
 FEI YUE COMMUNITY SERVICES
COMMUNITY MENTAL HEALTH (COMIT)
REFERRAL FORM

Additional information (may include client’s other medical issues, financial means, family details,
hospitalization for psychiatric treatment, history of substance abuse, etc.):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Additional Documents:
Assessment attached
Psychological/ Social Report attached
Discharge/Medical Summary attached

At present, is the client receiving any kind of formal support and if so, what are they? 
No
Yes, Service Provider(s): _________________

Copyright @ 2021 Fei Yue Community Services

Updated: 8 Oct 2021