Referral

Referral Information

Child/Youth’s Name:
Referral Category: New Continuing
Birth Date (MM-DD-YY):
Gender: Male Female
Legal Guardian:
Caregiver:
Partners: Human Services
CFS FSCD PDD AISH
Education
Health
Homecare Child and Adolescent Mental Health Glenrose
Other
Date Submitted:

Reason for Referral (Check all that apply):

Requires Additional Supervision / Requires Specialized Placement / Requires Respite Support
Staff Shortage in Area of Need / Mandate Issue / Flexible Integrated Support Required
Waiting Lists / Policy Issue / Need For Coordinated Planning
Unavailable Facility/Equipment / Other:

Child/Youth’s Name:

Child/Youth’s Strengths & Areas of Need:

Existing Diagnosis (i.e. Developmental Conditions, Physical/Motor Conditions, Mental Health, Sensory Impairments, Medical Conditions):

September 18, 20141

Child/Youth’s Name:

Current Support Summary

September 18, 20141

  1. Currently Provided Support – Assistance with Activities of Daily Living
    (Check all supports that apply):

Administering Medication
Catheterizing
Diapering
Dressing
Oral Feeding Assistance
Grooming
Tube Feeding
Management/Care of equipment required for
activities of daily living
Suctioning/Trach Care
Toileting
Other:
Not Applicable
  1. Currently Provided Support – Specialized Child Care Services
    (Check all supports that apply):

Out of School Care
Respite Care
Sibling Care
Other:
Not Applicable
  1. Currently Provided Support – Educational Services
    (Check all supports that apply):

Individual/Small Group Instruction
Regular Classroom
Sponsored to Special Program
Training
Other:
Not Applicable
  1. CurrentlyProvided Support – Out of Home Placement:
    (Check all supports that apply):

Addictions Facility
Foster Care - General
Foster Care - Treatment
Group Care
Medical/Auxiliary Care Facility
Mental Health Facility
Out of Home Respite
Relative/Kinship Care
Residential Care
Secure Services
Shared Care Between Many Placements
Shelter
Significant Adult/Other
Specialized Contract Placement
Support Independent Living
Other:
Not Applicable

September 18, 20141

Child/Youth’s Name:

  1. Currently Provided Support – Specialized Equipment, Supplies and Medical or Assistive Devices: Yes No

If yes, what types of supports are in place?

September 18, 20141

  1. Currently Provided Support – Professional Services
    (Check all supports that apply):

Audiology/Hearing Counseling
Behavioral Consultation
Dietary/Nutrition
Family Counseling
Mental Health Service/Therapy
Nursing
Occupational Therapy
Pediatrician
Physical Therapy
Psychiatry
Psychologist - Private/Educational
Reading/Literacy
Respiratory Therapy
Social Work
Special Education Consulting
Speech Language Therapy
Technology Consulting
Transliteration
Vision Consulting
Other:
Not Applicable

Currently Provided Support – Paraprofessional Services
(Check all supports that apply):

Community Support Worker
Cultural/Native Liaison Worker
Education Assistant
Emotional/Behavioral Assistant
Enhanced Adult Supervision
Family Support Worker
Interpreter/Translator
Job/Life Skills Coach
Nursing Assistant
Rehabilitation Therapy Assistant
School Liaison Worker
Youth Worker
Specialized Aide in Day Care
Other:
Not Applicable
  1. Currently Provided Support – Travel Within Alberta
    (Check all supports that apply):

Adult Supervision
Transportation
Other:
Not Applicable

September 18, 20141

Child/Youth’s Name:

Complex Case – Integrated Plan

Local Team Lead:

As the Local Team plans for the identified needs of a child/youth with complex needs, identify services (and itemized costs) that are currently in place to support the child/youth in the following environments:

Summary of Current Supports

Home Environment / Community Environment / School Environment
School Jurisdiction:
Alberta Health Services:
Human Services:
Other:

“Ask”

Identify gaps in services the Local Team is requesting for the child/youth
(include itemized costs): / Service / Hours / Cost per hour / Total

Child/Youth’s Name:

School Authority / Alberta Health Services / Human Services
Name:
Organization:

Signature of Local Team Lead: ______

September 18, 20141

Child/Youth’s Name:

Complex Case – Case Plan

Partners Involved with the Child/Youth:

Functional Impact:

Lead Agency:

Identify Gaps:
Plan to address need
(include costs and who is responsible):
Outcome Expected
(if funding received):
Measures
(how do you know that you have reached your outcome):
Other:

September 18, 20141

Child/Youth’s Name:

Regional Review Final Decision

To be completed by the Regional Manager. This section is completed upon review of the case.
Regional Review Decision

Decision Date (MM-DD-YY):
Decision Category: Approved Not Approved Partial
Referral Renewal/Closure

To be completed by the Regional Manager. This section can be completed at any time during the school year, but must be completed by the August 31 of school year that the referral was received.

Renewal

Renewal Date (MM-DD-YY):
Continue Into Next Year New Case Plan Completed

Closure

Closure Date (MM-DD-YY):
Not Approved Moved Out of Region Transition to Adult Services Other:

September 18, 20141