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Child & Youth Mental Health Algorithm - GPSC

Child & Youth Mental Health Algorithm - GPSC

Support PlanDate

Support PlanDate (mm/dd/yy):_______________From (Referral Agency):Name of Physician/Clinician/Psychiatrist (Agency): _____________________________________Phone: ______________________________________ Fax:_____________________________To:□□School Counsellor: ________________________ School: _________________________Fax: ____________________________________(This document will be stored in the school’s permanent student record)Other (e.g. family physician):Name/Agency: __________________________________ Fax: ____________________Name/Agency: __________________________________ Fax: ____________________Re:Student’s Name: __________________________________________________________(first)(last)Student’s Birthdate:__________________(mm/dd/yy)Consent provided by: ___________________________________________________________________Student has been seen by referral agency □ Yes □ No, missed appointment □ On waitlistAssessment has been completed (optional) □ Yes □ NoReferral agency will continue to see student (optional) □ Yes □ NoAdditional referrals to (optional): _________________________________________________________Recommendations for student school accommodations (optional):_______________________________Please call referral agency to discuss: □ School Counsellor □ Referring Physician(Optional)□ Other ________________________________44_CYMH_PSP_Support_Plan.2011_06_14 1 of 1

Patient Name:Date of Birth:Physician Name:MRN/File No:Date:CADDRA Teacher Assessment FormAdapted from Dr Rosemary Tannock's Teacher Telephone Interview.Reprinted for clinical use only with permission from the BC Provincial ADHD Program.Student's Name: Age: Sex:School:Grade:Educator completing this form: ____________________________________ Date completed: ______________________How long have you known the student? _________________ Time spent each day with student: ___________________Student's Placement: ___________________________________ Special Ed: Yes No Hrs per week: __________Student's Educational Designation: ___________________________________________________________NoneDoes this student have an educational plan?: Yes NoACADEMIC PERFORMANCEWell Below Somewhat Below At Grade Somewhat Above Well AboveGrade Level Grade Level Level Grade Level Grade Level n/aREADINGa) Decodingb) Comprehensionc) FluencyWRITINGd) Handwritinge) Spellingf) Written syntax (sentence level)g) Written composition (text level)MATHEMATICSh) Computation (accuracy)i) Computation (fluency)j) Applied mathematical reasoningCLASSROOM PERFORMANCEWell BelowWell AboveAverage Below Average Average Above Average Average n/aFollowing directions/instructionsOrganizational skillsAssignment completionPeer relationshipsClassroom BehaviourCADDRA TEACHER ASSESSMENT FORM 1/3117

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