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Date of referral: Reason for referral: Name: Date of Birth: Ethno-Cultural Self-Identification: No Yes specify Black e.g. African Black, American Black, Canadian Black, West Indian Black, Other Black South Asian e.g. Bangladesh, Indian(India), Pakistani, Sri Lankan Asian e.g. Chinese, Fijian, Japanese, Korean, Polynesian West Asian e.g. Arab, Armenian, Egyptian, Iranian, Lebanese, North African Arab Latin or Mediterranean e.g. Latin American of Spanish or Portuguese descent Caucasian e.g. Whites of European ancestry or descent Aboriginal e.g. North American natives including Inuit and Mtis Other e.g. Australian Aboriginal, Central and South American Aboriginal Unknown Internal use only (Comments): Client (Legal Custody): Parental joint custody Parental (Single Parent) identify parent:_____________________ Childrens Aid Society Crown ward Childrens Aid Society Society or Temporary ward Childrens Aid Society Temporary Care Agreement Independent Other: specify: ____________________________ Prohibited contacts:___________________________________ Internal use only (Comments): Clients Current Living Setting: Family Natural _________Extended_________Adopted________ Foster Home Friends Home Group Home Homeless, Hostel Hospital, Treatment facility Medical Independent Currently in detention Other: specify________________________ Family Issues/Concerns/Dynamics Lack of family support to provide care Inability to meet the needs of the child Family conflict/distress Parent/Child conflict Family break-up Substance abuse Physical or mental health issues Other specify: _____________________ Internal use only (Comments): Diagnosis, current medications & doctors name & date assessed: Doctors name: __________________________________________ Date of assessment: _____________________ Medication(s):__________________________ ___________________________ ___________________________ Attention Deficit Disorder Attention Deficit Disorder with hyperactivity Communication disorder Bipolar Tourettes Syndrome Obsessive Compulsive Disorder Conduct Disorder Oppositional Defiant Disordre Post -Traumatic Stress Disorder Depression Other specify: _____________________________ Internal use only (Comments): Intellectual/Adaptive/Functional Developmental delay Autism Spectrum Disorder Deficits in Intellectual Function Intellectual Disability/Specific diagnosis: ___________________________ Internal use only (Comments): Thoughts, Perception and Mood Disturbances/Disorder Disturbances in Thought Process Anxiety Continued Excited Mood Labile Mood Depression Suicidal Ideation Suicidal Gesturing Substance use/Abuse (If applicable what type of drug(s) and to your knowledge, when did the youth last used?)______________________________ ________________________________________________________________ ________________________________________________________________ Internal use only (Comments): Physical /Sensory Neurological or brain damage Sleep disturbances Enuresis Encopresis Sensory deficits/disorder Psycho-Physiological Incontinence Visual/hearing impairment Mobility limitations Communication limitations Other specify: _______________________ Internal use only (Comments): Victimization Sexual Abuse Physical Abuse Emotional Abuse Reported abuse to: ______________________________________ Bullying/being bullied/Threats Exploited Other specify: ______________________________________ Internal use only (Comments): Socialization Lack of peer friendship/relationship Social isolation Vulnerability Unable to communicate Internal use only (Comments): Aggression (Verbal) Peers Adults People in position of Authority specify: ____________________________________________________________________________________________________________ Internal use only (Comments): Aggression (Physical) Peers Adults People in position of Authority specify: ____________________________________________________________________________________________________________ If applicable - (weapon used) Internal use only (Comments): Psychological, Educational, Clinical assessments: Include photocopies of all testing performed (WISC III SCORES, FUNCTIONING LEVELS) School and Learning Current school placement (name) & grade level: Lack of support School Phobia Academic Under achievement Specific Learning Disability Transportation problems Other specify: ___________________________ Education synopsis: Description of current charges: (including any historical young offender status) Current charges: Probation: Start date: End date: Any upcoming court appearance: Internal use only (Comments): Past placements (list dates and reason placement broke down) & other agency involvement (outpatient/inpatient services) Other health concerns e.g. - allergies, asthma: _____________________________ ______________________________________________________________________ Previous successful interventions (brief description): Youths strength and Interest: What would help the youth feel welcome? : RELEVANT BACKGROUND INFORMATION: Please indicate family background, significant events, family history of psychiatric disorder and any relevant history. Attach additional pages as necessary. If a youth as been deemed a successful candidate, the following documents are required upon admission: Health Card Copy of Birth Certificate Updated Immunization Record Valid health insurance (Green shield etc..) Medication (refilled for at least 30 days) Report Card from last School attended ***Secure Treatment Program only Original and sealed Secure Treatment order must be available upon admission. 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