DLL-0359-A Referral for the Guichet d`accès jeunesse en santé

N° Dossier : _____________________
Sexe
M
F
Nom : ________________________________________________
Prénom : _____________________________________________
*DLL-0359*
Date de naissance : _______/_______/_____________
Jour
Mois
Année
DLL-0359
REFERRAL FOR THE « GUICHET D’ACCÈS JEUNESSE EN SANTÉ MENTALE »
CLSC Dorval-Lachine
LaSalle
Name of the referent : ___________________________
Function : ______________________
Tel. no. : ______________________________________
Fax no. : _______________________
__________________________________
Signature
Instruction for completion
___________________
Date
Please attach all documents necessary for the review of the file
A response on the orientation of your application will be faxed within 3 weeks
1. CHILD
Name :____________________________________________ First name : __________________________________
Date of birth
__________ /_____/______ Age : ____________
Permanent address : _____________________________________________________________________________
Language spoken :
French
English
Other
________________________ Sex : F
M
School : _______________________________________________ Additional services : ______________________
Name of doctor : _______________________________________________________________________________
Health Insurance Number (obligatory) : ______________________________
Did the child receive other medical services at the CLSC? Yes
Exp.date : _________________
No
If yes, specify : ________________________________________________________________________________
2. PARENT’S IDENTIFICATION
Mother :
Father :
Address :
Address :
Home :
Work :
Home :
Work :
Emergency number :
Occupation :
Occupation :
Language spoken :
Language spoken :
Date of birth :
Date of birth :
USER RECORD
REFERRAL FOR THE « GUICHET D’ACCES JEUNESSE EN SANTÉ MENTALE »
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*DLL-0359*
Nom, prénom: ____________________________
DLL-0359
IMMIGRATION STATUS
Country of origin
# Dossier: ________________________________
Father
Mother
Child
Civil status
Year of arrival
Occupation
Schooling
3. SIBLINGS
Name
First name
Âge
4. FAMILY ENVIRONMENT
Nuclear Family (parents living with their children)
Single parent family which child
Mother
lives with :
Date of separation / divorce :
Who is the legal guardian : Mother
Father
Reconstitued family which child Mother
lives with ::
Child lives in youth centre or with foster parents :
Where ? ______________________________________
PROFESSIONNALS /
ORGANIZATIONS
NAME AND ADDRESS
Father
Shared custody
Father
Other
Since : ____________________
DATE
BEGINNING
END
DIAGNOSIS
IF AVALAIBLE
Family doctor
Psychologist
Child psychiatrist
Social worker
Speech therapist
Neurologist
Audiologist
Special education teacher
Occupational therapist
Psycho educator
Batshaw Youth Services
Readaptation
Centre
(CRDI & CRDP)
Others :
USER RECORD
REFERRAL FOR THE « GUICHET D’ACCES JEUNESSE EN SANTÉ MENTALE »
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*DLL-0359*
DLL-0359
Nom, prénom: ____________________________
# Dossier: ________________________________
SERVICES OFFERED WITHIN THE SCHOOL FRAMEWORK
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
If you include reports or other documents which answer some of the questions on the form, it is not necessary
to supplement the following sections.
5. HEALTH AND DEVELOPMENT HISTORY (prematurity, diseases, complications, delays in development,
medication, hospitalizations, etc.)
6. SIGNIFICANT EVENTS (School, moving, migration any kind of violence, any kind of abuse, loss, financial
difficulties, disease of a relative, war, etc.)
7. WHAT IS THE MOTIVATION OF THE CHILD/FAMILY TO COMPLETE THIS APPLICATION FORM ? WHY
CONSULTING NOW ?
8. DESCRIBE CONCRETELY THE ACTUAL PROBLEM (Duration, frequency, intensity)
Area concerned (ex.: health, behaviour, family life, school life, social life, etc.)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
USER RECORD
REFERRAL FOR THE « GUICHET D’ACCES JEUNESSE EN SANTÉ MENTALE »
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*DLL-0359*
DLL-0359
Nom, prénom: ____________________________
# Dossier: ________________________________
9. IS THERE A SUICIDAL OR HOMIDICAL RISK? IF YES, EXPLAIN
10. IDENTIFY THE RISK AND PROTECTION FACTORS
Social network
Social contact
Many friends / relatives
Some friends / relatives
Few friends / relatives
Absence
Very frequently
Frequently
More or less frequent
Rare
Very rare
Relationship with others
Very good relationships
Good relationships
More or less good
Conflicting relationships
Inadequate relationships
Self image
Very positive
Positive
More or less positive
Negative
Very negative
Child was victim of :
Relationship with the family
(intra / extra)
Very good relationship
Good relationship
More or less good
Conflicting relationship
Inadequate relationship
Adaptability Capacities
Adapt very easily
Adapt easily
Adapt more or less easily
Difficult to adapt
Very difficult to adapt
Negligence
Incest
Sexual abuse
Act of violence / attack
Intimidation
Others : ____________________________
11. FAMILY HISTORY IN THE MEDICAL AND MENTAL HEALTH
12. WHAT IS THE MOTIVATION OF THE CHILD / FAMILY TO COMPLETE THIS APPLICATION FORM ? WHAT
ARE THEY READY TO DO AND WHAT ARE THEIR EXPECTATIONS ?
USER RECORD
REFERRAL FOR THE « GUICHET D’ACCES JEUNESSE EN SANTÉ MENTALE »
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*DLL-0359*
DLL-0359
Nom, prénom: ____________________________
# Dossier: ________________________________
13. CONSENT TO RECEIVE SERVICES
I hereby authorize ________________________________________ (name of referent) of the establishment /
institution _______________________________________________ to send all pertinent information relative to study
of my dossier by the Youth Guichet Access of the CSSS Dorval-Lachine-LaSalle.
I authorize the interveners of the Youth Guichet Access of the CSSS Dorval-Lachine-LaSalle to inform
_____________________________________ (name of referent) of the orientation of the services.
I hereby consent to participate in the follow-up that will be offered by CSSS Dorval-Lachine-LaSalle or the Douglas
Institute.
Signature of the father ____________________________________________________
And
Signature of the mother ___________________________________________________
Or
Youth (14 years and over) _________________________________________________
Consent of both parents or adolescent 14 years and over obligatory
Please return the completed application form by fax to Youth Guichet Access:
Fax number :
514-639-0659
Telephone:
514-639-0660 ext. 80537.
USER RECORD
REFERRAL FOR THE « GUICHET D’ACCES JEUNESSE EN SANTÉ MENTALE »
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