please read before filling out a referral form

Box5389,Westlock,ab,T9P2P5PediatricClinic,[email protected],[email protected],780-974-7112

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*PLEASEREADBEFOREFILLINGOUTAREFERRALFORM*

ThecriteriaREQUIREDbyNWCFASDNetworkinordertodoanFASDassessmentare:

ConfirmationofPrenatalAlcoholExposure(PAE)MUSTaccompanythesubmissionofthisreferralformandMUSTcomefromoneormoreofthevalidsourceslistedbelow:

• Ifbirthmotherisalive,confirmationofPAEMUSTcomefromher.

• Ifthebirthmotherisdeceasedand/orcannotbelocatedconfirmationofPAEMUSTbeobtainedfromthematernalsideofthefamily(excludingcurrentcaregiver)and/orfromagencyfiledocumentation

• BiologicalfatherorhisfamilyCANNOTprovidePAEconfirmation

1. Didbirthmotherconsumealcoholintheamountofsevendrinksormoreperweekatleasttwiceduringpregnancy?Yes_______No________

2. Didbirthmotherconsumefourormoredrinksatatimeonatleasttwoseparateoccasionsduringpregnancy?Yes__________No_________

IfyoudidnotansweryestoeitherofthetwoquestionsyoudonotmeetthecriteriatohaveanFASDAssessmentdone.

IfyouansweredyestoeitherofthetwoquestionsandtheconfirmedPAEcomesfromoneofthevalidsourceslistedabovepleasefilloutthereferralform.

[email protected]

Ifyouhaveanyquestions,[email protected]

780-284-3415,[email protected]


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Assessment&DiagnosticsServicesReferralForm

Date:_____________________________________

ReferralSource:

Name:______________________________________________________________________________

Agency:_____________________________________________________________________________

Address:___________________________________________PostalCode:______________________

Phone:_____________________Cell:____________________Email:__________________________

ClientInformation

ClientName:__________________________________________________

Male_____Female_____Other______

Name@birth(ifdifferentfromabove):__________________________________________________

DateofBirth:__________________________HealthCareNumber:___________________________

Address:_______________________________________________PostalCode:_________________

Home:______________________Work:_______________________Cell:_____________________

Hospitalatbirth:____________________________________________________________

Primarylanguagespoken1._____________________________2.______________________________

CultureOrigin:FirstNations_____Metis_____Inuit______Caucasian______AfricanAmerican______

Hispanic_____Asian_____Other________________________________________________________

OnReserve:Yes_____No_____Treaty#________________Band:__________________________

SelfIdentifying:FirstNations_______Metis_______Inuit________


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ContactInformation

NameofParents/Caregivers:___________________________________________________________

Address:________________________________________Postalcode:________________________

Phone:__________________Cell:___________________Email:_____________________________

LegalGuardian(s):____________________________________________________________________

Address:________________________________________PostalCode:________________________

Phone:__________________Cell:_________________Email:________________________________

Copyof2piecesoflegalguardianIDenclosed:Yes_____No_____

GuardianshipEnclosed:Yes_____No_____NA_____

CurrentSupportorAgencyinvolvement

Name:____________________________________Agency:__________________________________

Address:____________________________________________PostalCode:____________________

Phone:______________________Cell:________________________Fax:______________________

Email:______________________________________________________________________________


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Assessment&DiagnosticsServicesIntakeForm

IsChild&FamilyServices(CFS)currentlyinvolved?Yes_____No______

Ifyes,atwhatlevel:___________________________________________________________________

Caseworker:_______________________________Agency:__________________________________

Address:_____________________________________________PostalCode:___________________

Phone:_____________________Cell:________________________Fax:_______________________

Email:______________________________________________________________________________

HasCFSeverbeeninvolved?Yes______No_____

FamilyDoctor:_______________________________Clinic:__________________________________

Address:__________________________________________PostalCode:_______________________

Phone:_______________________________Fax:__________________________________________

Arethereanylegalorpendingcourtdates?Yes_____No_____

Ifso,pleaseprovidedetails_____________________________________________________________

____________________________________________________________________________________

Listalltheplacementstheclienthashadfrombirththroughtoage18

PlacementType Community Duration ClientAge Reason


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Assessment&Diagnosis

Haveanyassessmentsbeencompletedtodate?Yes_____No_____

Ifsoattachcopiesorlistassessmentsandnameoftheprofessionalinvolved____________________________________________________________________________________

____________________________________________________________________________________

Pleasecheckallareasofconcernwithbriefexplanation:

_____FASDrelatedfacialfeatures_______________________________________________________

_____FASDrelatedbehaviors__________________________________________________________

_____Problemsathome_______________________________________________________________

_____Problemsatschool/work_________________________________________________________

_____Work/SchoolReadiness__________________________________________________________

_____Work/SchoolAttendance_________________________________________________________

_____Learning/Academic______________________________________________________________

_____Cognition/Memory______________________________________________________________

_____Fine&orGrossMotorSkills_______________________________________________________

_____Speech/Language_______________________________________________________________

_____Social/friends__________________________________________________________________

_____Bullying/Cyberbullying___________________________________________________________

_____SubstanceAbuse________________________________________________________________

_____Troublewiththelaw_____________________________________________________________

_____Sleep_________________________________________________________________________

_____Suicideattempt/Ideation_________________________________________________________


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_____Health/Lifestyle_________________________________________________________________

_____ReproductiveHealth_____________________________________________________________

_____Medical_______________________________________________________________________

_____AbstractConcepts(time/money)___________________________________________________

_____Hyperactivity/Impulsivity_____Attention_____Emotional/Mood

Whataretheclient’sstrengthsandinterests?_____________________________________________

____________________________________________________________________________________

Extra-curricularActivities(sports,hobbies):_______________________________________________

CulturalActivities:____________________________________________________________________

Spiritual/ReligiousActivities:___________________________________________________________

CurrentProgramInvolvement

Doestheclientcurrentlyattendaschoolortrainingprogram?Yes_____No______

NameofSchoolofProgram:_____________________________________________Grade:_________

Istheclientcurrentlyemployed?Yes_____No_____

HealthHistoryWastheclientbornwith(orlaterdiscoveredtohave)anybirthdefects(e.g.cleftpalate,congenitalheartdefects,clubfoot,etc.)?Yes_____No______Unknown_____Ifyes,pleaseexplain__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HastheclienthadanyChronicIllnesses?

Ifyespleaseexplain___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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Hasthisclienthadanysurgeriessincebirth?Yes_____No_____

Ifyes,pleaseexplain__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Hastheclienthadanyhospitalizationssincebirth?Yes_____No_____

Ifyes,pleaseexplain _________________________________________________________________________________________________________________________________________________________________________________________________________________

Otherhistoricalhealthrelatedissues

Yes No

PhysicalAbuse

SexualAbuse

Didaphysicianevaluatethis?

EmotionalAbuse

Neglect

WitnesstoViolence

Other

Neurological/MentalHealthHistory

Hasthisclienteverhadseizures?Yes_____No_____

Bedwettingorsoilingafter8yrsold?Yes______No______

Isthiscontinuingtoday?Yes_____No_____


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Headinjuryleadingtounconsciousness?Yes_____No_____

CTorMRIscanofbrain?Yes_____No_____

Ifyeswherewasthisdone?___________________________________________________________

HasclienteverbeendiagnosedwithADD/ADHD?Yes_____No_____

Ifso,ageofevaluation?_____________________________________________________________

Treatmentprescribed?_____________________________________________________________

ListofCurrentMedications/Treatments:

________________________________________________________________________________________________________________________________________________________________________

PregnanciesofBiologicalMother(includingmiscarriageandabortion)

Year Lengthofpregnancy

Nameofchild

BornAlive

NormallyDeveloped

Behavioral/LearningProblems

OtherDiagnosis

Yes No Yes No

Ifmorespaceisneeded,pleaseuse“AdditionalInformation”onpage14


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FamilyMedicalHistory

BirthMother

BirthFather

BirthMother’sFamily

BirthFather’sFamily

Siblingsfull/half

AlcoholUse

Alcoholism

PrematureDeathrelatedtoAlcohol

FASD

BirthDefectsRelatedtoAlcohol

OtherBirthDefects

DevelopmentalDelays

ADD/ADHD

Autism

LearningDisorders

VisionProblems

HearingProblems

Childhoodbedwetting

SeizureDisorders(epilepsy)

Othermedicalconditions

Schizophrenia


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FamilyMedicalHistoryContinued BirthMother

BirthFather

BirthMother’sFamily

BirthFather’sFamily

Siblingsfull/half

Depression

Suicide/SuicidalIdeation

PTSD

Bi-polarDisorders

OtherMentalHealthIssues

PhysicalAbuse

SexualAbuse

ChildhoodNeglect

EmotionalAbuse

FamilyViolenceIssues

TroublewiththeLaw

Other

BiologicalFamilyHistory

BirthMother:________________________________________________________________________

Birthdate:_____________________Phone:___________________Cell:______________________

AttimeofClient’sbirth:

Age:__________MaritalStatus________________________________________________________

LivingSituation/Accommodations________________________________________________________


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Historyof:Learning/EmploymentDifficulties:______________________________________________

BirthFather:__________________________________________________

Birthdate:_____________________Phone:___________________Cell:______________________

Historyof:Learning/EmploymentDifficulties:______________________________________________

SubstanceUseHistory

Describebirthmother’slife1yearbeforeclientwasborn:___________________________________________________________________________________________________________________________________________________________________________________________________________

Describebirthmother’ssociallifeatthetimeatthetimeofthepregnancy:_____________________________________________________________________________________________________________________________________________________________________________________________

Didthebirthmotherhaveanychronicillnesses,mentalhealthrelatedconcerns,stressrelatedcircumstancesduringthepregnancy?Ifso,pleasedescribe:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Whattypesofalcohol(beer,wine,coolers,liquor)didbirthmotherconsumeduringpregnancy.________________________________________________________________________________________________________________________________________________________________________

Whatpartofherpregnancywasthealcoholconsumed?1sttrimester_____2ndtrimester_____3rdtrimester_____

Howmuchalcoholwasconsumedthroughoutthepregnancy?

1-3drinks 4-9drinks 10+drinks


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Howoftenwasalcoholconsumedthroughoutthepregnancy?

Daily Weekly Monthly

Whattypesofandhowoftenweresolvents,ifany,didbirthmotherdrinkduringpregnancy.Solventsarethingslikemouthwashorcleaningsuppliesthatcontainalcohol.________________________________________________________________________________________________________________________________________________________________________

Didthebirthmothersmokecigarettesduringthepregnancy?Yes_____No_____

Howmanycigarettesperday?_______________________

Duringwhichpartofherpregnancy?1sttrimester_____2ndtrimester_____3rdtrimester_____

Didthebirthmotherusedrugs(prescriptionand/oroverthecounter)duringthepregnancy?

Yes_____No_____

Ifso,whattype(s)?___________________________________________________________________

Duringwhichpartofthepregnancy?1sttrimester_____2ndtrimester_____3rdtrimester_____

Sourceofthisinformation(fullnameandrelationshiptotheclient)_______________________________________________________________________________________________________________

PresentSituation

Pleasedescribehistoryofcontactwithabsentbirthparents,siblings,maternalextendedfamilyandpaternalextendedfamily:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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Listallthepersonslivingintheclient’scurrenthomeandtheirrelationship.

Name Age RelationshiptoClient


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AdditionalInformation

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Assessment & Diagnostic Services

Authorization to Obtain Information

I, (full legal name of parent or legal guardian),

hereby authorize the Northwest Central Alberta Fetal Alcohol Spectrum Disorder Network to obtain the

following information verbally or in writing pertaining to:

(Child’s name), (Date of Birth)

Please INITIAL and place an (X) beside the information to be obtained.

Birth records and other medical records (Including newborn discharge summaries, nursing notes and immunization records)

Past and current educational records

Speech, language, psychological, and other assessments

Children’s Services Records

Justice or Correctional Services Information, reports and history

Mental Health Assessments, reports, and history

Other: This information will be used to assist the Northwest Central Alberta FASD Network Diagnostic team to determine a diagnosis, develop continuum of care recommendations and to make appropriate referrals. This consent form is to be effective for the duration of the client’s involvement with the assessment, diagnostic and intervention services and may be withdrawn by the client/legal guardian at any time during this process.

Signature of Parent / Legal Guardian Date

Relationship to Client

Signature of Witness Date

Name of Witness

Legal Guardianship Order attached? Yes No Not Applicable

REHABILITATION Consent for Services

The collection of the above individually identifying health/personal information is authorized under the Health Information Act and/or the Freedom of Information & Protection of Privacy Act. The purpose of the collection allows Alberta Health Services – Aspen to follow up and investigate when

appropriate. REH.S1.025 (2009-02) Page 1 of 2

Name:______________________________

DOB:_______________________________

Phone #:____________________________

Affix Client’s Label here (if Applicable)

Speech / Language Services Respiratory Therapy Services Occupational Therapy Services Physiotherapy Services

*Please check (√) the appropriate service required (one service only)

Section I – Consent for Services

I, on behalf of consent to: (Client / Parent / Legal Representative) (Client’s Name) a) Participation in an assessment, consultation and/or treatment as may be deemed necessary and that Alberta

Health Services – Aspen, Health Service Providers will or may perform such assessment, consultation and treatment. This may include practicum students or colleagues in training.

b) A Health Service Provider, with my involvement, will develop and implement a treatment plan to help reduce my symptoms and improve my ability to function. Treatment may also include coordination of my case plan with other relevant service providers.

I understand that: c) This consent is effective as of , and expires on the (Day / Month / Year) (Day / Month / Year) d) I may, at any time, refuse to undergo any particular assessment, consultation and/or treatment or accept

recommendations for treatment

e) The particular treatment will be undertaken in the Province of Alberta and that the Courts of Alberta shall be the only ones that have jurisdiction to entertain any complaint, demand, claim or cause of action, should the Client decide to commence any such legal proceedings against Alberta Health Services or any of its Affiliates

Signature of: Client or Agent or Guardian (Note: Agents and Guardians are legal representatives. An agent

can only be appointed pursuant to a personal directive)

(Signature) (Day / Month / Year)

(Witness Printed Name) (Witness Signature)

Section II – Alternate Consent

Consent has been received, but unable to obtain sig nature because: Signature of Health Service Provider

OR

Telephone Fax Other:

Name:

Legal Status to Client: Client or Other (Specify): (Day / Month / Year)

(Witness Printed Name) (Witness Signature)

(One witness (health provider) should confirm consent for Clients unable to sign and fax telephone consent)

REH.S1.025 (2009-02) Page 2 of 2

Section III – Obtaining Consent of a Non-English Sp eaking Client

I acknowledge that I have interpreted the contents of this Consent Form to the Client and I believe that the Client understands the contents.

(Interpreter’s Printed Name) (Signature of Interpreter) (Day / Month / Year)

Section IV – Consent to Disclose Health Information

I, on behalf of (Client / Parent / Legal Representative) (Child’s Name) am hereby authorizing the disclosure of individually identifying Assessment, Consultation, and/or Treatment information for services provided between the specified dates of this consent in Section I. This consent for Disclosure is in accordance with the Health Information Act.

This information is to be provided to for the purpose of extended treatment. (Name of Agency)

I understand that: a) That the information on this form is collected under the Alberta Health Information Act and will be used to comply

with this request to disclose the above specified individually identifying health information

b) Why I have been asked to disclose my individually identifying health information, and am aware of the risks and/or benefits of consenting, or refusing to consent to the disclosure of this information

c) That my consent will be valid as per the specified duration dates in Section I and that it may be resc inded at any time as long as it is in writing by myself o r my authorized representative, and

d) A photocopy or facsimile of this form shall be deemed as valid as an original

(Signature of Client/Parent/Legal Representative) (Home Phone Number) (Day / Month / Year)

(Print Name of Client/Parent/Representative) (Relationship to Client – please attach a copy of Authority to Act)

(Signature of Witness) (Printed Name of Witness) (Day / Month / Year)

Consent to Disclose Health Information

18028(2011-10)

The patient/client or his/her authorized representative must complete this form before AHS may disclose thepatient’s/client’s health information to someone else (unless Alberta’s Health Information Act authorizesdisclosure without consent). The information on this form, together with any record authorizing a representativeto act on behalf of the patient/client, is being collected under part 3 of the Health Information Act for thepurpose of recording the patient’s/client’s consent to the specified disclosure and will be filed on thepatient/client record. For questions about this collection of information, contact the program area that providedyou this form or contact the Chief Privacy Officer at 10301 Southport Lane SW, Calgary, AB T2W 1S7 or call1.877.476.9874. Patient/client name

Date of birth (yyyy-Mon-dd) Personal health number (authorized by HIA s.21(1))

Address

Details of health information being disclosed (write in full without abbreviations, include dates of treatment)

Identify below where records exist

Health service provider, hospital, clinic, program City/Town

Date consent is effective (yyyy-Mon-dd) Expiry date (valid for 2 years if no date)(yyyy-Mon-dd)

Name of individual(s)/organization(s) information is being disclosed to

Purpose(s) of disclosure

Authority of person(s) giving consent (If signing on behalf of the patient/client, indicate your authority below and providea copy of the document which authorizes you)o Guardian (or Trustee) - of a minor under the age of 18 years, who is not determined to be a mature minor

- named in a Guardianship Order/appointed under the Adult Guardianship andTrusteeship Act, if access to health information relates to the powers and duties of the guardian (or trustee)o Nearest relative under Mental Health Act - if access to health information is necessary to carry outobligations of the nearest relative o Agent - appointed in an enacted personal directive according to the Personal Directives Acto Personal representative - of a deceased patient, if the access to information relates to administration ofthe individual’s estateo Power of attorney - if access to health information relates to the powers and duties of the attorneyo Written authorization - any written authorization from the individual to act on the individual’s behalfo Specific decision maker - as defined in the Adult Guardianship and Trusteeship Act

I authorize AHS to disclose the health information described above to the individual(s) or organization(s)identified above. I understand why I have been asked to disclose my individually identifying information. I amaware of the risks and benefits of consenting, or refusing to consent, to the disclosure of my healthinformation. I understand that I may revoke this consent in writing at any time.

Name of person giving consent Signature Date (yyyy-Mon-dd)

Phone Address City/Town Province Postal Code

Name (last, first)

Birthdate (yyyy-Mon-dd)

PHN# HRN# CoMIS#

City/Town Province Postal Code

Clinic Support

Typewritten Text

Clinic Support

Typewritten Text

Records of Immunization, Nursing Notes, Growth Charts (Head Circumference, Height, Weight); Developmental screens, SLP and OT Assessments

Clinic Support

Typewritten Text

Northwest Central FASD Network

Clinic Support

Typewritten Text

Clinic Support

Typewritten Text

Clinic Support

Typewritten Text

780-674-4141

Clinic Support

Typewritten Text

Box 4141BarrheadAB T7P 1A3

Clinic Support

Typewritten Text

Clinic for Assessment

Clinic Support

Typewritten Text

Authorization to Obtain/Release Information

I, _____________________________________________ hereby give permission for Randall

Symes Psychological Services, to obtain/release confidential information and/or records

pertaining to my child and/or myself ________________________________________

(D.O.B: ________________________) that would assist in their assessment and/or treatment.

These records will be held confidentially by Randall Symes Psychological Services.

Name and address of individual/agency from/for whom information is to be obtained/released:

Name of individual/agency:______________________________________________________

Address:_____________________________________________________________________

City:__________________________________ Postal Code:___________________________

Phone:_________________________________ Name of Contact: ______________________

____________________________________ ____________________________________

Print name of consenting person Relationship to child (if applicable)

____________________________________ ____________________________________

Signature Date

This release is valid for one year from the date shown

Consent for Educational/Psychological Assessment

Dear Parent/Guardian:

Your child ______________________________ (Date of Birth: ________________________)

has been referred for an educational/psychological assessment to be administered and/or

supervised by a registered psychologist from Randall Symes Psychological Services. The testing

may be in-person or through Telepsychology. Telepsychology services are provided via secure

internet technology as an alternative to face-to-face meetings and assessments. We use secure

video-conferencing technology with encryption to maintain a very high level of confidentiality.

This testing will provide insight into your child’s difficulties with learning and/or behaviour.

You may be asked to complete questionnaires which are optional, but they are intended to gather

information from your perspective. Please note that the questions may not be specific to your

child; however, it is important that you complete the forms as thoroughly as possible. Please feel

free to add any information that you feel is relevant. All information will be kept in a

confidential file and used only for the purposes of this assessment.

Upon receipt of your written consent to conduct the assessment, which may involve a review of

your child’s student file at their school, arrangements will be made for the evaluation. Your

child’s teacher may also be asked to complete a package of questionnaires. The results of the

evaluation will be shared with you on the date of the evaluation, or shortly thereafter. If you

have any questions, please do not hesitate to contact the school or our office at (780) 434-6466.

I give consent for an educational/psychological assessment for the child/adolescent named

above.

___________________________________ ____________________________________

Print name of consenting person Relationship to child

___________________________________ ____________________________________

Parent/Guardian Signature Date

Northwest Central Alberta FASD Network Assessment & Diagnostic Services 1

Assessment & Diagnostic Services Consent to Release Information

I, (full legal name of individual or

legal guardian), hereby authorize the Northwest Central Alberta Fetal Alcohol Spectrum Disorder

Network to RELEASE the following information verbally or in writing pertaining to:

(Name), (Date of Birth)

This information is to be released to the following identified sources. Please specify the

information to be RELEASED by selecting the corresponding letter from list below (i.e. A-F) AND

by placing your INITIALS beside each selected item.

A. Assessment & Diagnostic Services Summary Report and Recommendations

(Short 1-Page Summary Report)

B. Psychological Assessment Report

C. Speech Language Assessment Report

D. Occupational Therapy Assessment Report

E. Medical Summary Report

F. All Reports Listed Above

Initials Information Source

Family Doctor

School Division

Family Supports for Children with Disabilities

Other: (e.g. AMHS, AISH, CFSA, FCSS)

Program evaluation and research

Signature of Client/ Parent/Legal Guardian Date

Relationship to Client Signature of Witness Date

Print Name of Witness

Box5389WestlockABT7P2P5780-305-9547or780-974-7112

Assessment&DiagnosticServicesConsenttoReleaseInformation

I, _____________________________________________, (full legal name of parent or legal guardian) hereby authorize the Northwest Central Alberta Fetal Alcohol Spectrum Disorder Network to release information pertaining to myself and/or my child, ________________________________(Child’s name), _______________________________ (Date of Birth) to Jordan’s Principle funding of the First Nations and Inuit Health Branch Department of Indigenous Services Canada/Government of Canada and to the First Nations Health Consortium..

Please INITIAL and place an (X) beside the information to be obtained

□ _______ Child’s Name

□ _______ Child’s date of birth

□ _______ Child’s Treaty Status Number

□ _______ Mailing address

□ _______ Documentation of need (psychological assessment, speech language assessment, professional letters of support)

□ _______ Approval of funds being dispensed to NWC FASD Network for Assessment and Diagnostic costs

Parent/Guardian Signature Date

___________________________________ _______________________________

Parent/Guardian Name (printed)

_______________________________________________

*please read before filling out a referral form*

Documents

please read before filling out a referral form