Child And Adolescent Mental Health Assessment Page 2
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3Child & Adolescent Mental Health Assessment and Treatment Referral
(Edmonton Zone)
Reason for Referral /Current Concerns
What are your expectations of treatment? Are you requesting a specific service, program, clinic, etc?
Are school supports involved with this child/youth?
£ No
£ Yes
(eg., speech/language/OT/PT, consulting services)
Has any psychological testing been done on this child? £ No
£ Yes If yes, please attach reports
Physician/Pediatrician
Name
Phone
Fax
Doctor is aware of referral
£ Yes
£ No
Medication, Vitamins, Herbal Supplements
Allergies
Page 2 of 3
18344(2013-01)
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Parent category: Medical