Children’s Health Queensland Child and Youth Mental Health Service Referral to CYMHS Day Programs	(Patient label location for paper form) URN: Family name: Given names: Address: Date of birth: Sex: M F I

Young people who benefit from a day program Those recovering from complex mental health difficulties with associated significant functional impairment in home, social and educational settings Those currently experiencing poor school attendance or education engagement and reengagement with face-to-face education or vocational activities is an identified goal Those who have previously engaged in a multidisciplinary package of community care (CYMHS or private) that has not succeeded in improving functioning Those who can safely participate in individual, group and family therapy and the educational setting Those with family/carers able to participate in family-focused intensive mental health intervention and who can facilitate daily attendance of the young person PRIOR TO COMPLETING REFERRAL FORM - contact relevant Day Program: Jacaranda Place Day Program (ages 13-17yrs in CHQ north Bne catchment) (07) 2105 6000 Day Program South (ages 5-12yrs in CHQ Bne catchment, 13-17yrs in CHQ south Bne catchment) (07) 3068 2500 Referral to Day Program Jacaranda Place Day Program South at Queensland Children’s Hospital (QCH) Referrer details Date of referral: Click or tap to enter a date. Name: Phone: Service / Team: Parent / carer details Name: Relationship to young person: Address: Phone (H): (W): (M): Email: Name: Relationship to young person: Address: Phone (H): (W): (M): Email: Family structure (young person's current living situation)? Intact family Single parent (separated/divorced) Step or blended family Other: Relevant clinical information Young person’s current working diagnoses Primary diagnosis: Secondary diagnoses: Formulation Presenting (detailing impact on functioning at home, school and with peers), Predisposing, Precipitating, Perpetuating and Protective Clarifying information What mental health interventions have previously been offered and the outcomes? Detail previous assessments completed e.g. cognitive, speech and language, sensory and the outcomes? What have been the barriers to recovery? Number of inpatient admissions (Mental Health or Medical but related to mental health difficulties): Number of Mental Health presentations to emergency departments in the last 12 months: Current medications: Previous medications: Risks – this section is mandatory Are there any concerns that the young person is at significant risk of harming themselves or others? Is the young person an absconding risk, or are they regarded as vulnerable? No Yes - give a brief account and describe mitigating strategies considering group environment Are there any other risks? e.g. domestic or family violence, history of Child Safety involvement, legal issue No Yes - specify below Is the Department of Communities (Child Safety Services) involved in this young person’s care? No Yes - name of Child Safety Officer and Service Centre: Are there any legal issues? (e.g. Family Law Court, Youth Justice, compensation claim/s, young person a victim/witness in upcoming trial, Domestic Violence Orders, Treatment Authorities) No Yes - specify below Risk assessment completed on CIMHA: N/A for private referrers Yes - date: Click or tap to enter a date. School information Current or last school enrolled in and grade: Pattern of school attendance and duration of difficulties: (e.g. refusal to attend, difficulty engaging, level of support required at school) Brief history of schooling: (contributing or mitigating factors for school engagement - academic ability, behavioural concerns, history of bullying, peer relationships, family relationship to education) Goals for Day Program engagement (as discussed with young person and parent/carer) Day Program Use Only – Referral Outcome Name of staff member receiving referral: Signature: Designation: Date of intake team discussion: Outcome: Accepted Declined Deferred for further information Rationale: