Regional Collaborative Service Delivery
Complex Case – Referral Form
Referral
Referral Information
Child/Youth’s Name:
Referral Category:
New
Continuing
Birth Date (MM-DD-YY):
Gender:
Male
Female
Legal Guardian:
Caregiver:
Partners:
Human Services
CFS
FSCD
PDD
AISH
Education
Health
Homecare
Child and Adolescent Mental Health
Glenrose
Other
Date Submitted:
Reason for Referral (Check all that apply):
September 18, 2014
Requires Additional Supervision
Requires Specialized Placement
Requires Respite Support
Staff Shortage in Area of Need
Mandate Issue
Flexible Integrated Support Required
Waiting Lists
Policy Issue
Need For Coordinated Planning
Unavailable Facility/Equipment
Other:
1
Child/Youth’s Name:
Child/Youth’s Strengths & Areas of Need:
Existing Diagnosis (i.e. Developmental Conditions, Physical/Motor Conditions, Mental Health, Sensory Impairments, Medical Conditions):
September 18, 2014
2
Child/Youth’s Name:
Current Support Summary
1.
Currently Provided Support – Assistance with Activities of Daily Living
(Check all supports that apply):
Administering Medication
Catheterizing
Diapering
Dressing
Oral Feeding Assistance
Grooming
Tube Feeding
Management/Care of equipment required for
activities of daily living
Suctioning/Trach Care
Toileting
Other:
Not Applicable
2.
Currently Provided Support – Specialized Child Care Services
(Check all supports that apply):
Out of School Care
Respite Care
Sibling Care
Other:
Not Applicable
September 18, 2014
3.
Currently Provided Support – Educational Services
(Check all supports that apply):
Individual/Small Group Instruction
Regular Classroom
Sponsored to Special Program
Training
Other:
Not Applicable
4.
Currently Provided Support – Out of Home Placement:
(Check all supports that apply):
Addictions Facility
Foster Care - General
Foster Care - Treatment
Group Care
Medical/Auxiliary Care Facility
Mental Health Facility
Out of Home Respite
Relative/Kinship Care
Residential Care
Secure Services
Shared Care Between Many Placements
Shelter
Significant Adult/Other
Specialized Contract Placement
Support Independent Living
Other:
Not Applicable
3
Child/Youth’s Name:
5.
Currently Provided Support – Specialized Equipment, Supplies and Medical or Assistive Devices:
Yes
No
If yes, what types of supports are in place?
6.
Currently Provided Support – Professional Services
(Check all supports that apply):
Audiology/Hearing Counseling
Behavioral Consultation
Dietary/Nutrition
Family Counseling
Mental Health Service/Therapy
Nursing
Occupational Therapy
Pediatrician
Physical Therapy
Psychiatry
Psychologist - Private/Educational
Reading/Literacy
Respiratory Therapy
Social Work
Special Education Consulting
Speech Language Therapy
Technology Consulting
Transliteration
Vision Consulting
Other:
Not Applicable
September 18, 2014
Currently Provided Support – Paraprofessional Services
(Check all supports that apply):
Community Support Worker
Cultural/Native Liaison Worker
Education Assistant
Emotional/Behavioral Assistant
Enhanced Adult Supervision
Family Support Worker
Interpreter/Translator
Job/Life Skills Coach
Nursing Assistant
Rehabilitation Therapy Assistant
School Liaison Worker
Youth Worker
Specialized Aide in Day Care
Other:
Not Applicable
7.
Currently Provided Support – Travel Within Alberta
(Check all supports that apply):
Adult Supervision
Transportation
Other:
Not Applicable
4
Child/Youth’s Name:
Complex Case – Integrated Plan
Local Team Lead:
As the Local Team plans for the identified needs of a child/youth with complex needs, identify services (and itemized costs) that are currently in place to support the
child/youth in the following environments:
Summary of Current Supports
Home Environment
Community Environment
School Environment
School Jurisdiction:
Alberta Health Services:
Human Services:
Other:
“Ask”
Service
Hours
Cost per hour
Total
Identify gaps in services the Local
Team is requesting for the
child/youth
(include itemized costs):
September 18, 2014
5
Child/Youth’s Name:
School Authority
Alberta Health Services
Human Services
Name:
Organization:
Signature of Local Team Lead: _____________________________________
September 18, 2014
6
Child/Youth’s Name:
Complex Case – Case Plan
Partners Involved with the Child/Youth:
Functional Impact:
Lead Agency:
Identify Gaps:
Plan to address need
(include costs and who is
responsible):
Outcome Expected
(if funding received):
Measures
(how do you know that you have
reached your outcome):
Other:
September 18, 2014
7
Child/Youth’s Name:
Regional Review Final Decision
To be completed by the Regional Manager. This section is completed upon review of the case.
Regional Review Decision
Decision Date (MM-DD-YY):
Decision Category:
Approved
Not Approved
Partial
Referral Renewal/Closure
To be completed by the Regional Manager. This section can be completed at any time during the school year, but must be completed by the August 31 of school year that
the referral was received.
Renewal
Renewal Date (MM-DD-YY):
Continue Into Next Year
New Case Plan Completed
Closure
Closure Date (MM-DD-YY):
Not Approved
September 18, 2014
Moved Out of Region
Transition to Adult Services
Other:
8