CRM-F1
Restricted
Application Form for Placement in
School for Social Development/Residential Home
This
document
is
subject to irregular
update as needed.
The online version shall
always apply.
(4/2013 version)
For day placement:
Please return the completed form to SI(SES2), Special Education Support 2
Section, Room 201, East Block, Education Bureau Kowloon Tong Education
Services Centre, 19 Suffolk Road, Kowloon Tong, Kowloon. (Fax. No. 2760
4191, Tel. No.: 3698 3727)
For day and residential
placement/after-school
care programme in
residential service:
Please complete the form in duplicate. One copy is to be returned to SI(SES2)
of EDB (Fax. No. 2760 4191, Tel. No.: 3698 3727) and the other copy to SS(C)2,
Corrections Section, Social Welfare Department, Room 735, Wu Chung House,
213 Queen’s Road East, Wan Chai, Hong Kong. (Fax. No. 2833 5861, Tel. No.:
2892 5106)
I.
Personal Particulars of the Student
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1. Name:
2. Sex:
M/F
Chinese:
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4. Student Reference No. (STRN) :
5. Address in English:
Address in Chinese:
Home Tel.:
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Age:
(DD/MM/YYYY)
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Place of birth:
Date of birth:
3. H.K.I.C./B.C. No.:
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6. Name of parent/guardian:
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Chinese:
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7. Parent’s/Guardian’s mobile phone number: 按 一 下 輸 入
8. SWD/NGO/EDB file ref. no. (if any):
9.
Health
Conditions:
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Satisfactory
Unsatisfactory *Please specify problem(s) 按 一 下 輸 入
10. Name
)
of School attending/last attended:
Highest class level:
II.
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(按 一 下 輸 入 school year)
Suggested Placement (Please tick in the appropriate box/es)
1. Day Placement
FOR OFFICIAL USE ONLY
Placement in
a school for social
development
is/is not recommended
2. Day & Residential Placement
3. Day Placement & After-School Care Programme in Residential
Service
4.
Please tick if the above option is for Short Term Adjustment
Programme
(
Please state the school preferred, if any：:按一下輸入
1
for Vetting Committee of
CCRM
Date:
)
III. Other information about the student
Please tick in the appropriate box/es
1.
Record of
Attendance
Regular
Irregular
Non-attending since (date):
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Remarks (if any): 按一下輸入。
2.
was suspended from school
withdrew of own accord
was asked by the school to withdraw
is attending school
Student
3.
Student’s intention to resume/continue schooling
4.
Academic
performance
Primary
Secondary
Low
Average
High
Below average in baisc subjects
Failed poorly in baisc subjects
Please describe the student’s school/learning history and academic attainment:
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5. Intellectual Assessment Name of assessment tool:按一下輸入
Date of assessment:按一下輸入日期(DD/MM/YYYY)
Full Scale IQ:按一下輸入
If the student has not been assessed, please estimate his/her general intellectual abilities.:
Average
Suspected slow learning
6.
Behaviour Primary
選擇一個項目。
Secondary 選擇一個項目。
Please describe the student’s social, emotional and behavioural problems. Illustrate with concrete
examples and state clearly in what circumstances these problems are more severe and how frequent
they occur.
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7.
Main problems (please refer to P. 8 for the codes)
Behaviour Manifested 按一下這裡以輸入文字。
Code:選擇一個項目。 Others (please specify): 按一下這裡以輸入文字。
Mild
8.
Moderate
Severe
Other problem(s) (please refer to P. 8 for the codes)
Behaviour Manifested 按一下這裡以輸入文字。
Code:選擇一個項目。 Others (please specify): 按一下這裡以輸入文字。
Mild
2
Moderate
Severe
9.
Statutory supervision record :
No
Yes
In process
(a) Police Superintendent Discretionary Scheme
Offence:
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Period: 按一下輸入。
(b) Care or Protection Order
Reason:
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Residential care has been provided:
Period: 按一下輸入。
Yes
No
(c) Probation Order
Offence:
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Has been admitted to Probation Home:
Period: 按一下輸入。
Yes
No
(d)Others(please specify):按一下輸入
Period: 按一下輸入。
10. Work experience(if applicable):
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11. Student’s strengths and potentials:
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12. Record of previous school/residential placement, if any (Please state the period of placement, the
performance of the student and the reasons for discharge):
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13. History of abscondence from home (if applicable):
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3
IV. Family Support
1. Family background (may tick more than 1 box) :
intact family
parent(s) in prison
single parent/split family
parent(s) mentally unstable
living with relatives
parent(s) remarried
parent(s) with disability or ill
health
parent(s) with chronic illness
parent(s) with marital discord
parent(s) with criminal conviction
others (please specify):
2.
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Particulars of family members and relatives living with the student:
Name
(English)
(Chinese)
Relationship
with student
Sex
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M/F
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M/F
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M/F
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M/F
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M/F
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M/F
3.
Attitude of parents/guardians towards the student:
Supportive and
Indifferent
Rejecting
committed
Supportive but ineffective
Neglectful
Abusive
4.
Overall impression on family support:
Adequate To be
inadequate
improved
5.
Parents’/guardian’s willingness to co-operate with professionals:
Willing to take advice
6.
Unmotivated to seek/ follow advice
Age /
Date of Birth
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期。
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期。
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期。
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期。
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期。
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期。
Occupation
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Reject professional help
Please describe the student’s relationship with family members/their ways of communication and
parenting style.
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4
7.
Please describe the significant events in the family leading to the need of after-school care
programme/residential placement. This item must be completed for application for residential
placement or after-school care programme in residential service.
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8.
Please choose one below (*delete as appropriate). This item must be completed for application for
residential placement or after-school care programme in residential service.
This case
has been / will be * referred to casework service unit (e.g. Integrated Family Services
Centre, Medical Social Service Unit, Family and Child Protective Services Unit, Probation Office) for
follow up throughout the placement period.
Casework Service Unit: 按一下輸入
Contact Person: 按一下輸入
Contact Tel: 按一下輸入
The organisation to which the referrer of this application belongs will provide family services to
the student and the family, and will follow up the needs of the student after he/she has been
admitted to the residential home.
V. Have the school personnel, social worker, guidance personnel or other professionals rendered support
to the student? If yes, please give a detailed account of the support and the effectiveness. (Please
use separate sheet if necessary.)
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VI. Previous services sought from EDB/SWD/DH/HA/NGO:
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5
VII. Report(s) attached: (please tick as appropriate)
The referrer should submit copies of the attached reports on the student to the relevant school for
social development/residential home for reference together with the application form. Consent
from the parents/guardian or the report issuing agencies should be obtained before submission.
Yes, the following report(s) is/are attached:
Latest school report
Medical report
Psychologist's/counsellor's report
Others (Please specify:)
Psychiatrist's report
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No
VIII. Student’s attitude towards the referral and participation during the process:
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IX. Parents’/guardian’s attitudes towards the referral and participation during the process:
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X.
Future plan and follow-up service for the student formulated by the referrer:
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XI. Present residential placement of the student: (tick one only)
at home
at relatives' home
in hospital
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in residential unit/foster home (please
specify:)
in remand home/place of refuge (please
specify:)
others: (please specify):
under the care of child-minder
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period of remand:按一下輸入
date of next court hearing::按一下輸入日
期。
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6
Remarks:
I confirm that consent has been obtained from parents/guardian to this referral for placement in a school
for social development/residential home.
Signature of referrer:
Countersigned by
SWO/Centre-in-charge/School Head:
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(Name in block letters)
(Name in block letters)
Position/Rank: 按一下輸入
Position/Rank: 按一下輸入
Agency / Unit / School: 按一下輸入
Tel. No. (School):
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Fax. No. (School):
Tel. No. (Agency):
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Fax. No. (Agency): 按一下輸入
E-mail :
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Date:
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7
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Codes for items III7 and III8
Behavioural Problems at School
Pre-delinquent/Delinquent Behaviour
S1
Poor School Attendance/Truancy
D1
Acts of Physical Violence against Person or
Property
S2
Poor Teacher-Student Relationship
D2
Abscondence from Home
S3
Disruptive Behaviour in Class
D3
Staying Out/Staying Out Overnight
(e.g. bullying, yelling, hyperactivity)
D4
Gang/Pseudo-triad /Triad Involvement
Breaking School Regulations
D5
Taking, Possessing or Trafficking Drugs
(e.g. foul language, signature forgery,
frequent lateness, smoking, cheating in
tests/examinations, stealing)
D6
Stealing/Shoplifting
Others (please specify)
D7
Cult Involvement
D8
Sexual Promiscuity or Frequenting/Working in
Vice Establishment(s)
D9
Others (please specify)
S4
S5
Emotional/Psychological/Mental Health Problems
P1
Suicidal Tendency/Symptoms
P2
Anxieties (e.g. School Phobia)
P3
Withdrawn and Moody Behaviours
P4
Obsessive Act
P5
Emotionally Unstable/Impulsive Behaviour
P6
Others (please specify)
8