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Family Information Form

Personal Information - Required by Saskatchwan Health


The information supplied must match the individuals Saskatchewan Health Card.

Child's First Name(*)
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Child's Last Name(*)
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Child's Middle Name(*)
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Gender
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Child DOB(*)
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Child's Personal Health #(*)
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Mother's Information


Mother's Name (as on health card)
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Mother's DOB
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Mother's Personal Health #
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Father's Information


Father's Name (as on health card)
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Father's DOB
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Father's Personal Health Number
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If mother and/or father’s personal health number is unknown at time of referral, leave blank and ensure information is provided at the child’s first appointment.


Contact Information


Child's Home Address(*)
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Home Phone Number
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Guardian's Address
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Guardian's Phone Number
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Name of Child’s Primary Contact or Legal Guardian(*)
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Parent Contact Numbers


 

Family Information


Family Living with Child Age Occupation/Grade Relationship to Child

Family living apart from child


Father's Information

Is the Father in contact with the child?


Mother's Information

Is the Mother in contact with the child?


Please Describe Contact / Visiting Arrangements
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Is the Department of Child and Family Services involved with your family?
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CFS Worker\s Name and Contact #
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In your own words, what are your concerns about your child? When did it start?
 

Medical History


Does your child take medications?
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Does your child have any allergies?
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Does your child have any health problems currently?
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Has your child ever experienced a head injury, loss of consciousness, or seizure?
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Does your child have any chronic medical problems?
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Does your child have a history of any serious injuries or medical hospitalizations?
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Has your child ever had any surgeries?
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Does your child have chronic pain (frequent headaches, stomach aches, chest pain)?
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Has your child ever had an EEG, MRI, CT SCAN, etc?
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If Yes, Please Provide Details:
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Medications


List of all Medications Dose and duration of use Was it effective?

 

 

 

Mental Health History


Has your child a history of or been treated for any of the following?

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If yes, please provide details
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Has your child been involved or received services from the following?
Child Protective Services
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Speech and language therapy
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Early Intervention Services (ages 0-3)
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Mental Health Services
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Counsellors or Psychologists (list names)
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Has your child seen a psychiatrist in the past?
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Please provide names and age at which child was seen.
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Family History


Depression
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Anxiety
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Panic Attacks
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Post-Traumatic Stress
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Bipolar / Manic Depression
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Schizophrenia
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Alcohol Problems
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Drug Problems
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ADHD
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Suicide Attempts
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Psychiatric Hospital Stay
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Other history not included above:
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Development and Academic History


Current grade level
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Current School
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What are your child’s academic strengths?
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What are your child’s academic weaknesses?
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Has there been a change in your child’s performance at school?
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If ‘Yes’, please describe.
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Has your child received IQ or Academic testing?
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If ‘Yes’, where was it done?
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Does or has your child participated in any of the following?

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Has Your Child struggled with the following?

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Please explain:
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Social History


Are there any stressors or struggles your family is currently facing?
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If Yes, please describe
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Has your child ever been the victim of abuse or neglect?
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If yes, check all that apply

{Victim of abuse or neglect choose:validation}

Are you struggling with your marital relationship or parenting? If yes please explain:
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Has your child ever been bullied?
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Are you concerned regarding your adolescent’s friendships?
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Has your child ever bullied other children?
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Are you concerned that your adolescent is using (or has used) drugs (including over the counter medicines) or alcohol? If ‘Yes’, please explain:
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Are you concerned about high risk behavior (sexual activity, speeding, self-harm, suicide)? If ‘Yes’, please explain:
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