IS THE INFANT/CHILD/YOUNG PERSON AT IMMEDIATE RISK TO THEMSELVES OR OTHERS? Yes No If yes, please call 000 or have the infant/child/young person present to Emergency Department Have you obtained consent for this referral from child/young person’s legal guardian? Yes No Child/young person? Yes No If no, please indicate reason in the Mental Health Concerns and Relevant Family History section below SECTION 1: INFANT / CHILD / YOUNG PERSON DETAILS Family name: Given name: Preferred name: Date of birth or EDC: Sex recorded at birth: Gender: Address: Phone: Alerts and allergies: Country of birth: Interpreter required? Yes No Preferred language: Aboriginal or Torres Strait Islander origin: Aboriginal Torres Strait Islander Both Neither Medicare eligible: No Yes – Card number: Card reference: Expiry: / Is the infant/child/young person in ‘out of home’ residential care? Yes No If yes, which Child Safety Service Centre: Contact name: Phone: Is the infant/child/young person in the guardianship of Department of Child Safety? Yes No Are there any custody or guardianship issues? Yes No If yes, details: Are there current Family Law Court Orders in place? Yes No If yes, details: Is the parent/carer the infant/child/young person’s legal guardian? Yes No Is the legal guardian the preferred contact? Yes No PARENT/CARER DETAILS Parent Legal Guardian Other (specify): Name: Relationship to infant/child/young person: Address: Email: Contact number: Interpreter required? Yes No Preferred language: Parent Legal Guardian Other (specify): Name: Relationship to infant/child/young person: Address: Email: Contact number: Interpreter required? Yes No Preferred language: PLEASE SPECIFY WHICH CYMHS SERVICE YOU ARE REFERRING Community Clinics Eating Disorder Program Zero to Four Dr Stephen Stathis Dr Stephen Stathis Dr Stephen Stathis Please note: Named referrals assist service sustainability, support patient choice and workforce retention. CYMHS consumers are case managed by multi-disciplinary teams and may or may not be treated in person by a Medical Officer. SECTION 2: PRESENTING CONCERNS Are there any psychosocial vulnerabilities? Infant / Child / Young Person Yes No Unknown Parent / Carer / Family Yes No Unknown If yes, details: Any current or history of self-harm or suicidality? Infant / Child / Young Person Yes No Unknown Parent / Carer / Family Yes No Unknown If yes, details: Known or suspected history of violence and/or aggression? Infant / Child / Young Person Yes No Unknown Parent / Carer / Family Yes No Unknown If yes, details: Current delusions or hallucinations? Infant / Child / Young Person Yes No Unknown Parent / Carer / Family Yes No Unknown If yes, details: Current or previous issues with substance misuse? Infant / Child / Young Person Yes No Unknown Parent / Carer / Family Yes No Unknown If yes, details: Known disability or developmental history that restricts everyday activities? Infant / Child / Young Person Yes No Unknown Parent / Carer / Family Yes No Unknown If yes, details: PHYSICAL EXAMINATION – Mandatory for Referrals to Eating Disorders Service’ Current height: Blood pressure Lying: Standing: (after 2 mins) Current weight: Pulse Lying: Standing: (after 2 mins) Urine Specific Gravity: Blood Glucose Level: Temperature: Investigations (including ECG and blood test results) SECTION 3: ADDITIONAL INFORMATION IF REFERRING TO ‘EATING DISORDERS’ Please provide a detailed history of the eating issues, including details about WHY you think the child/young person may/does have an eating disorder (attach additional documentation/information as required). Please outline the reasons for referring to the Eating Disorders Team e.g. diagnostic clarification, second opinion, treatment for primary eating disorder. Please provide historical height and weight history (ie. please attach weight/height percentile chart or list below). SECTION 4: ADDITIONAL INFORMATION IF REFERRING TO ‘ZERO TO FOUR’ Please provide a detailed history of your ‘concerns for the unborn / infant / young child – parent relationship e.g. infant/young child-parent interactions; capacity of parent to notice and respond to the child’s social and emotional and physical needs; presence of hostility / intrusiveness; absence of delight and positive interaction. OBSERVATIONS AND GOALS / OUTCOMES DESIRED FOR THE UNBORN / INFANT/ CHILD / YOUNG PERSON Please provide your observation in relation to sleeping or eating difficulties, appearing anxious or stressed, withdrawn or depressed, disinhibited / over-familiar, unsettled, irritable or dysregulated, aggressive behaviours. SECTION 5: OTHER MENTAL HEALTH CONCERNS AND RELEVANT MEDICAL / SURGICAL / DEVELOPMENTAL / FAMILY HISTORY Current medications: OTHER SERVICES / TREATMENT PROVIDERS CURRENTLY INVOLVED Name: Agency: Contact number: Name: Agency: Contact number: Name: Agency: Contact number: Name: Agency: Contact number: REFERRER DETAILS (REQUIRED) Name: Designation/role: Organisation: Provider no: Address: Phone: Fax: Email:

Signature: Double-click on the X to sign	Date:
External to Queensland Health please consider the Privacy Obligations for secure sending of Health Information Please FAX your completed form to: 07 3068 4329
Queensland Health and Department of Education staff can submit a referral directly to Children’s Health Queensland Central Referrals Hub by clicking on SUBMIT below, or by FAX: 07 3068 4329