Child And Adolescent Mental Health Assessment Page 3
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3Child & Adolescent Mental Health Assessment and Treatment Referral
(Edmonton Zone)
Current Agencies or Services Involved
Phone
Fax
Child and Family Services Status
Young Offender’s Status
(if applicable)
(if applicable)
£ Assessment in process
£ Charges Pending
£ Enhancement Agreement
£ On Probation
£ Supervision Order
£ Alternate Measures
£ Custody Agreement
£ Court appearance scheduled on
______________
£ Temporary Guardianship Order
£ Permanent Guardianship Order
£ Secure Services
Psychiatric /Medical/Developmental History
(please attach relevant documents)
Previous Services Accessed
(please attach relevant documents)
£ Child Psychiatrist
£ Addictions Services
£ Inpatient Programs at Royal Alexandra Hospital
£ PCHAD (Protection of Children Abusing Drugs)
£ Inpatient Programs at Glenrose
£ Residential Care
£ Day Program at Glenrose
£ Play /Individual /Family Therapy
£ Glenrose Clinic
£ School Based Services
£ School-Aged Neurodevelopmental
£ Preschool Program
Assessment Clinic (SNAC)
£ Child and Family Services
£ Preschool Assessment Services (PAS)
£ Family Supports for Children with Disabilities
£ Mental Health Clinic
£ Youth Diversion
£ CASA Programs
£ Any Other Services
Additional Comments
Page 3 of 3
18344(2013-01)
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Parent category: Medical