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Family Information From B

Person Filling Out Form


Name
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Relationship to Child
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Personal Information - Required by Saskatchewan 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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Child's Home Address(*)
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City
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Postal Code
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Home Phone Number
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Alternate Contact Information
Work: Cell:
Work: Cell:

Mother's Information


(Note: SK Health requires we have the following information from parent/caregivers as well)

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


Father's Name (as on health card)
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Father's Personal Health Number
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Father's DOB
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Dear Parents/Caregivers


The following information will be helpful in improving our understanding of your child. Please fill in the blanks as thoughtfully as possible- do not leave blanks. If you do not know an answer, write "don't know".

In your words, what are your concerns about your child?
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When did the problems first begin?
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Are there circumstances, past or present, in your family's life that you connect with the current difficulties?
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Has your child suffered any significant losses?
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What made you decide to seek help?
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What have you done to attempt to improve the problem?
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What changes would you like to see as a result of your contact here?
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Family Information


Parents living with child:

Father (step): Age: Occupation:
Mother (step) Age: Occupation:

Date of current union/marriage
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Parents living without child:

Father

Father (step): Age: Occupation:
Address
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Telephone
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In contact with the child?
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If'Yes', how often?
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Mother

Mother (step): Age: Occupation:
Address
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Telephone
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In contact with the child?
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If'Yes', how often?
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Foster Parents/Guardians

Father: Age: Occupation:
Mother:

Age:

Occupation:


How long has the child been in your home?
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Is the Department of Social Services involved with your family?
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If Yes, Worker's Name
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Department of Social Services office
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Presently Living in the Home

List all other persons (including other children) who presently live in your home.
Name Sex Age

Relationship to Child

If child: is he/she Child biological, adopted, step or foster?

Occupation or Grade

 

Child’s Medical History


Is your child on medication?
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If 'Yes', what medication?
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Does your child have any medication allergies?
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If' Yes', please specify.
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Is your child physically well?
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Does your child have any health problems currently?
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If yes, please specify
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Has your child ever had any of the following?
Allergies   Hearing Problems
Bedwetting   Heart Problems
Broken Bones   Learning Problems
Clumsiness   Seizures
Ear Infections   Soiling
Eating/Weight problems   Speech Problems
Head Injury   Visual Problems

List any illnesses/injuries for which your child required hospitalisation and/or surgical operations.
Illness/Injury Doctor Date Hospital

 

Family Medical History


  Yes/No Who
Alcohol/drug problems
Anxiety
Bedwetting
Family Violence
Hyperactivity
Learning problems
Mental retardation
Mood disorder
Schizophrenia
Seizures
Speech problems
Soiling
Suicide
Others?  

Is any member of the family currently ill?
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If 'Yes', please explain
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Are any members of the family taking medications at the present time?
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If 'Yes', please explain:
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During the pregnancy, did the child's mother experience any illnesses, or accidents?
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Were any drugs (prescription or non-prescription), alcohol, or tobacco taken during pregnancy?
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Duration of pregnancy
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Duration of labour
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Birth weight
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Describe any difficulties with the delivery (e.g. Caesarean Section, medication required, breech presentation etc.)
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Following birth, did your child have trouble starting to breathe?
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Was anything unusual at birth or in the first few weeks of life Gaundice, seizures etc.)?
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If 'Yes', please specify
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Were developmental milestones like walking, talking, toilet training on track?
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If 'No', please specify
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Preschool History


Name of Program Child's Age Length of Time Attended
Has your child's behavior been of any concern at the pre-school, day care, or day home?
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If 'Yes', what were the concerns?
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School History


Name of present school
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Grade
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Teacher
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Other School City/Town/Province Year(s)

Grade(s)

Age

Has your child repeated a grade?
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If 'Yes', please specify
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Has your child had frequent absences from school or been absent for more than one month?
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If 'Yes' please specify
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Has your child's behavior been of any concern at elementary or high school?
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If 'Yes', what were the concerns?
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Child & Adolescent Psychiatry


Have any psychiatrists, agencies or counselors been involved in your child's care?
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 Name of Psychiatrist/Counselor/Agency

 Date(s) of Appointment(s)



Consent to Obtain and Release Information


The Child & Adolescent Psychiatrists in Saskatoon work together to provide patient care. To ensure that your child receives the best possible service, it may be necessary, from time to time, to communicate between offices on your behalf, both verbally and in writing, to other psychiatrists, physicians or professional mental health staff. All information obtained will remain confidential. I give my consent for my child's psychiatrist to obtain and release information.

Date
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