DEVELOPMENTAL BEHAVIOURAL REFERRAL
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- Mabel Ramsey
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1 Date DEVELOPMENTAL BEHAVIOURAL REFERRAL Completed By Role: Paediatrician/GP How long Other professionals involved with the child (e.g. psychologist, OT, speech therapist) Reason for this referral List a maximum of 3 things that you want from this consultation (list target behaviours/emotional issues) Describe briefly: Duration of Current problems 1 3 months 3 6 months 6 12 months 12 + months Known medical, surgical or developmental Diagnosis SPEECH PROBLEMS: Describe INTELLECTUAL DISABILITY Diagnosis: Age when diagnosis first made Cause of intellectual disability (if known) Has genetic testing been done? No Yes Date (yyyy-mon-dd) Results Developmental Disability Information (Please enclose a copy of any testing, if available) IQ Testing Full Scale Score Other testing (Adaptive, speech language, physiotherapy, Occupational Therapy, etc) Test Administered Date Examiner Results 1
2 ASD: Has the young person been diagnosed as suffering from an Autism spectrum disorder? No Yes (if available please enclose report) Family History or Mental Illness, Developmental Disabilities, Neurological Illness or Seizures List biological relatives who have a history of mental illness, mental handicap developmental disability, neurological illness or Seizures. This includes suicide attempts, severe substance abuse, psychiatric hospitalization and or treatment No information available Relationship to patient Illness Treatment Date Pregnancy and Delivery No information available During pregnancy was alcohol, drugs or medications used? Don t know No Yes Duration of Pregnancy (in months) Birth weight kg Apgar Score 1 minute 5 minutes Delivery Spontaneous Induced Caesarean Early Development Milestones Complications for pregnancy or delivery No Yes Sat Up Walked 1 st word Talked (Phrase) Trained Urine Trained Faeces Educational History List school/vocational placements attended Name Grade Attended Comments Professional Start Date End Date (if applicable) Role, frequency of consults and interventions tried Agencies involved (e.g. BIST, respite) Admission Date Discharge Date Comments: Frequency of contact, effectiveness of their interventions 2
3 Medical History No Yes Describe Seizure Disorder Abnormal EEG CT Scan MRI Tics or Tremors Any other type or neurological troubles e.g., headaches Specific communication disorder (e.g.inability to talk) Heart problem Respiratory problem (eg. Asthma) Stomach or intestinal problems Gynaecological problems (in teenage girls) Urinary problems Skin problems Orthopaedic problems Arthritis Allergies Impaired vision Impaired hearing Past Hospitalizations (Psychiatric/Medical/Surgery) Date Name of Hospital Describe Surgery or Reason for Hospitalization Current Physical and Mental Function Consider the previous 3 months in completing this inventory Physical Function Sleep Appetite Mood Thoughts (Unusual) Aggression Energy Level Concentration Ability Bowel and Bladder Concerns Menstrual Concerns Sexuality Concerns 3
4 Current Medications DEVELOPMENTAL BEHAVIOURAL REFERRAL Medications Dose Times/ Day Effect Adverse effects Date Started Previous Trials of Medications Medications Dose Start Date End Date Describe Result Name of Referring doctor Signature Date 4
5 ADDITIONAL MENTAL HEALTH INFORMATION Are there recent changes to mood, sleep and level of activity for the past 2 to 3 weeks or longer? If yes give details Has there been a recent decrease in functional ability (speech, communication, self care etc)? If yes give details Has been a recent increase in repetitive and ritualistic behaviours If yes give details Name of Referring doctor Signature Date 5
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