Referral form
Psychiatric Collateral Information
Collateral is information about a patient's mental state and function from someone other than the patient — a parent, partner, group home, teacher, or previous clinician. It is not gossip. It is a dated, consented, attributable note that psychiatry uses when the patient's own account is incomplete, minimized, or impossible to obtain.
Why collateral exists
First-episode psychosis, dementia, eating disorders, ADHD in adults, and capacity assessments often cannot be done from the patient's interview alone. A form (or a structured note) keeps the source, the date, and the observations separate from your opinion.
Hospitals and community agencies print their own collateral sheets. If you do not have one, a structured note with the same headings is better than a phone message that says 'mom says he's not himself.'
Consent is the first box
Capable adults decide whether you may speak to family. If they refuse, you may still receive unsolicited information; you document that it was unsolicited and you do not phone the family back for more without a legal exception (safety, substitute decision-maker, child protection). Write the consent status on the form.
Who completes it
- The psychiatrist, NP, GP, or social worker who took the collateral.
- The informant does not sign a clinical opinion. They sign only if the form asks them to confirm their own statements.
- Do not have a clerk 'just get some history' without a clinician responsible for what is recorded.
How to complete the form
- Informant name, relationship, how long they have observed the patient, phone, date of interview.
- Consent: obtained / refused / SDM / unsolicited.
- Timeline: when change started, what was first noticed, hospitalizations, substances, missed meds.
- Current function: sleep, food, hygiene, school or work, money, risk to self or others, driving, weapons.
- What the informant is afraid will happen this week — often more useful than a DSM debate.
- Discrepancies with the patient's account, stated as discrepancy, not as 'patient is lying.'
- Your name. Collateral without an author is not in the chart.
Worked example (fictional)
Mother — first-episode psychosis screen
Fictional 19-year-old patient. Do not copy into a real chart.
Informant: M. L., mother, same household 19 years. Interview 28 Aug 2026, 20 minutes, phone. Patient consented to this call today. Onset: 4–5 months. First noticed: talking to himself in the basement, covering the laptop camera. Last 3 weeks: not attending college, one meal a day, up most of the night. Meds: stopped a trial of sertraline 6 weeks ago on his own. No known street drugs that she has seen. One empty vodka bottle last month, not typical for him. Risk: no stated plan to harm others. She removed a hunting rifle from the house 10 days ago after he asked where it was 'for protection.' He has not driven in 2 weeks (she has the keys). Discrepancy: he told me he is sleeping 8 hours and 'just stressed about exams.' Mother: 2–3 hours, no exam registration this term. Informant request: assessment this week. Not asking for a Form 1 on this call. Recorded by attending GP; psychiatry referral sent.
Why collateral notes fail later
- No source name or date.
- No consent status.
- Mixing the informant's words with your diagnosis in the same sentence so you cannot tell them apart.
- Calling the school without consent in a capable adult.
- Using collateral as an LTD narrative without the patient's authorization to that insurer.
Draft collateral from the interview
In Scribeberry, open Forms, search for psychiatric collateral information, or upload your service's current PDF. Generate from the encounter and your notes, then edit every field before you sign. Scribeberry does not pre-map this form. You still review and sign.
Frequently asked questions
Can I record collateral if the patient says no?
You may document unsolicited information that arrives. You generally may not seek more from that person without consent or a legal exception. Write the refusal.
Is collateral the same as a Form 1?
No. A Form 1 is an Ontario psychiatric assessment order. Collateral may support your decision to complete one. It is not the order.
Should the informant see the note?
The note is part of the patient's record. Do not promise the informant confidentiality you cannot keep. Do not put third-party contact details in a report you will send to an insurer without thinking.
Does Scribeberry contact the family?
No. Scribeberry helps you complete the PDF or structured note from the interview you already did. You keep it in the chart.
Forms
