Fraser

Fraser Health Child and Youth Psychiatry General Teaching ClinicOur services:‣ The Fraser Health Child and Youth Psychiatry General Teaching Clinic serves families with children fromages six to 18, who live in Fraser Health.‣ The General Teaching Clinic provides initial assessment and consultation for children and youth with abroad range of child and adolescent mental health problems which may include depression, anxiety,general mood and behaviour disorders. The General Teaching Clinic also offers a tertiary service forchildren and youth with complex or treatment resistant mental health disorders.‣ The General Teaching Clinic serves children and youth in a teaching environment with psychiatricresidents and medical students. Short term treatment, including medication management and therapeuticinterventions are offered. Brief family therapy may also be available.‣ Participation in the clinic is voluntary.Our team:‣ The team members include psychiatrists, a clinical social worker and psychiatric residents/medical students.Referrals:‣ The clinic accepts referrals from general physicians, paediatricians and other medical specialists by fax to 604-587-3814. Please contact us for further information.‣ Children and youth accepted to the clinic will be assigned to a psychiatrist and to the clinical social worker and/orto a resident as appropriate. Families referred to this clinic must be willing to have their child or teenparticipate in a teaching environment for psychiatric residents and medical students.‣ Once the appointment day and time are made, the referral source and the parents/guardians will be notified. It isthe family’s responsibility to confirm the appointment with the clinic.‣ Referrals not deemed appropriate for the General Teaching Clinic will be redirected to other suitable services inthe community.Our location:Fraser Health Child and Youth Psychiatry Phone: 604-587-3814General Teaching Clinic Fax: 604-587-3857Shirley Dean Pavilion, Surrey Memorial Hospital9634 King George BoulevardSurrey, BC, V3T 0G7Respect, Caring, Trustwww.fraserhealth.ca

FRASER HEALTH CHILD AND YOUTH PSYCHIATRY CLINICSSERVING ALL OF THE FRASER HEALTH REGIONLocated at the Shirley Dean Pavilion, Surrey Memorial HospitalOutpatient Psychiatry, Shirley Dean Pavilion, 9634 King George Boulevard, Surrey, B.C. V3T 0G7Telephone: 604.587.3814; Fax: 604.587.3857REFERRAL FORM:Please check one of the following:□ CHILD AND YOUTH NEUROPSYCHIATRY CLINIC□ CHILD AND YOUTH PSYCHIATRY, GENERAL TEACHING CLINIC□ URGENT REFERRAL □ NON-URGENT REFERRALPART 1 – PATIENT INFORMATIONChild’s surname: _______________________ Child’s first name: _____________________DOB: month ______day ____year _____ Gender: male ____ female ____ transgender _______PHN: ____ ____ ____Address: _____________________________________________________________City________________________ Postal Code________________Day phone_______________ Cell phone _________________ Other phone_______________Please check preferred method of contact: □ day phone □ cell phone □ other phonePART 2 – PHYSICIAN INFORMATIONReferring Physician: ______________________________ Billing # _________Phone: ___________________ Fax: __________________Family Physician: ___________________________________Phone: ____________________ Fax: ____________________Additional physicians: _________________________________Phone: ___________________ Fax: ______________________PART 3 – CONSENTIt is essential that consent is obtained from both custodial parents prior to the referral. Pleaseconfirm that consent has been obtained: □ yes □ noWho should we contact to book the appointment? Name: ___________________________________________Contact number: ____________________ Relationship to the patient: ________________________________If MCFD is involved, please provide the name and phone number of the social worker:_________________________________________________________________________________________Is there a need for an interpreter? If so, please indicate the preferred language: _________________________PART 4 – PARENT AND LEGAL GUARDIAN INFORMATIONPlease list all parents and/or legal guardians:Surname: ________________ first name: ____________ Phone number_______________Relationship to child: ____________________Legal guardian: □ yes □ noSurname: ________________ first name: ____________ Phone number_______________Relationship to child: ____________________Legal guardian: □ yes □ noSurname: ________________ first name: ____________ Phone number________________Relationship to child: ____________________Legal guardian: □ yes □ noPlease indicate if there are any ongoing custody and/or access issues:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________