Adolescent COPE Referral Form Community Outreach of Pediatrics and Psychiatry in Education

Date Filled Out

/ /

Student

Student's Name

Preferred Name

Date of Birth / /

Gender

Alberta Healthcare Number

Parent/Legal Guardian #1

Name

Address

Postal Code

Work Phone

Home Phone

Cell Phone

Parent/Legal Guardian #2

Name

Address

Postal Code

Work Phone

Home Phone

Cell Phone

What question(s) are you hoping a physician can answer for you?

Maximum 650 Characters

Do you have a regular family doctor?

If Yes, Name

Phone

Have you had a Speech and Language Assessment?

Yes
No
I don't know

If Yes, at Age

Have you had Psychoeducational Testing?

Yes
No
I don't know

If Yes, at Age

Have you received any other assessments?

Maximum 650 Characters

Have you been given any diagnoses (e.g., Learning Disability, ADHD, Asthma…)?

Yes
No
I don't know

If Yes, what Maximum 650 Characters

Are you taking any medications?

If Yes, what Maximum 650 Characters

What other treatments have you received?

Maximum 650 Characters

Narrative Description of Child – Parent (IRS)

Centre for Children & Families, University of Buffalo

Instructions: In the spaces below, please describe what you see as your primary problems in each area, both at home and at school, and describe the effects of your problems in that area.

Then drag the slider towards the points that describe how much your problems affect each area and whether you need treatment or special services for the problems (see sample below)

1. How your problems affect your relationship with peers.

Maximum 650 Characters

No Problem

Extreme Problem

2. How your problems affect your relationship with brothers or sisters.

Maximum 650 Characters

No Problem

Extreme Problem

I do not have siblings

I do not have regular contact with siblings.

3. How your problems affect your relationship with your parents/guardians.

Maximum 650 Characters

No Problem

Extreme Problem

4. How your problems affect your academic progress at school.

Maximum 650 Characters

No Problem

Extreme Problem

5. How your problems affect your self-esteem.

Maximum 650 Characters

No Problem

Extreme Problem

6. How your problems affect your family in general.

Maximum 650 Characters

No Problem

Extreme Problem

7. Overall severity of your problem in functioning and overall need for treatment.

Maximum 650 Characters

No Problem

Extreme Problem

Do you have any other comments or concerns?

Maximum 650 Characters

Please list names and relationship of those living with you

Maximum 650 Characters

Have you seen a family doctor or a pediatrician in the past for the concerns stated above?

Have you seen a Pediatrician in the past?

What is the main language spoken at home?

The MTA SNAP-IV Rating Scale

1. Fails to give close attention to details or makes careless mistakes in schoolwork or tasks

Not at all
Just a little
Quite a bit
Very much

2. Has difficulty sustaining attention in tasks or play activities

Not at all
Just a little
Quite a bit
Very much

3. Does not seem to listen when spoken to directly

Not at all
Just a little
Quite a bit
Very much

4. Does not follow through on instructions and fails to finish schoolwork, chores or duties

Not at all
Just a little
Quite a bit
Very much

5. Has difficulty organizing tasks and activities

Not at all
Just a little
Quite a bit
Very much

6. Avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort

Not at all
Just a little
Quite a bit
Very much

7. Loses things necessary for activities (e.g., toys, school assignments, pencils, or books)

Not at all
Just a little
Quite a bit
Very much

8. Is distracted by extraneous stimuli

Not at all
Just a little
Quite a bit
Very much

9. Is forgetful in daily activities

Not at all
Just a little
Quite a bit
Very much

10. Has difficulty maintaining alertness, orienting to requests, or executing directions

Not at all
Just a little
Quite a bit
Very much

11. Fidgets with hands or feet or squirms in seat

Not at all
Just a little
Quite a bit
Very much

12. Leaves seat in classroom or in other situations where remaining seated is expected

Not at all
Just a little
Quite a bit
Very much

13. Runs about or climbs excessively in situations in which it is inappropriate

Not at all
Just a little
Quite a bit
Very much

14. Has difficulty playing or engaging in leisure activities quietly

Not at all
Just a little
Quite a bit
Very much

15. Is "on the go" or often acts as if "driven by a motor"

Not at all
Just a little
Quite a bit
Very much

16. Talks excessively

Not at all
Just a little
Quite a bit
Very much

17. Blurts out answers before questions have been completed

Not at all
Just a little
Quite a bit
Very much

18. Has difficulty awaiting turn

Not at all
Just a little
Quite a bit
Very much

19. Interrupts or intrudes on others (e.g., butts into conversations or games)

Not at all
Just a little
Quite a bit
Very much

20. Has difficulty sitting still, being quiet, or inhibiting impulses in the classroom or at home

Not at all
Just a little
Quite a bit
Very much

21. Loses temper

Not at all
Just a little
Quite a bit
Very much

22. Argues with adults

Not at all
Just a little
Quite a bit
Very much

23. Actively defies or refuses adult requests or rules

Not at all
Just a little
Quite a bit
Very much

24. Deliberately does things that annoy other people

Not at all
Just a little
Quite a bit
Very much

25. Blames others for his or her mistakes or misbehaviour

Not at all
Just a little
Quite a bit
Very much

26. Is touchy or easily annoyed by others

Not at all
Just a little
Quite a bit
Very much

27. Is angry and resentful

Not at all
Just a little
Quite a bit
Very much

28. Is spiteful or vindictive

Not at all
Just a little
Quite a bit
Very much

29. Is quarrelsome

Not at all
Just a little
Quite a bit
Very much

30. Is negative, defiant, disobedient, or hostile toward authority figures

Not at all
Just a little
Quite a bit
Very much

Additional Comments

Maximum 650 Characters

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