Adolescent COPE Referral Form (Christ the Redeemer) 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?

Do you have a regular family doctor?

If Yes, Name

Phone

Have you had a Speech and Language Assessment?

If Yes, at Age

Have you had Psychoeducational Testing?

If Yes, at Age

Have you received any other assessments?

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

If Yes, what

Are you taking any medications?

If Yes, what

What other treatments have you received?

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.

No Problem

Extreme Problem

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

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.

No Problem

Extreme Problem

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

No Problem

Extreme Problem

5. How your problems affect your self-esteem.

No Problem

Extreme Problem

6. How your problems affect your family in general.

No Problem

Extreme Problem

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

No Problem

Extreme Problem

Do you have any other comments or concerns?

Please list names and relationship of those living with you

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

2. Has difficulty sustaining attention in tasks or play activities

3. Does not seem to listen when spoken to directly

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

5. Has difficulty organizing tasks and activities

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

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

8. Is distracted by extraneous stimuli

9. Is forgetful in daily activities

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

11. Fidgets with hands or feet or squirms in seat

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

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

14. Has difficulty playing or engaging in leisure activities quietly

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

16. Talks excessively

17. Blurts out answers before questions have been completed

18. Has difficulty awaiting turn

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

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

21. Loses temper

22. Argues with adults

23. Actively defies or refuses adult requests or rules

24. Deliberately does things that annoy other people

25. Blames others for his or her mistakes or misbehaviour

26. Is touchy or easily annoyed by others

27. Is angry and resentful

28. Is spiteful or vindictive

29. Is quarrelsome

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

Additional Comments

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