Vancouver Regional Pediatric Team Consent Form

Transcription

1 Vancouver Regional Pediatric Team 2110 West 43 rd Avenue Vancouver, BC Canada V6M 2E1 Telephone (604) Facsimile (604) Vancouver Regional Pediatric Team Consent Form Child s Name: Date of Birth: The Vancouver Coastal Health Authority (VCH) Regional Pediatric Team (VRPT) helps children with special health care needs lead active, healthy lives in their homes, schools and communities. Our Pediatric Team of community health nurses, occupational therapists, physiotherapists and social workers provide one or more of the following: School-based consultation for children aged 5 to 19. Short-term therapy for children discharged from hospital. Assistance to children with complex medical nursing needs. Assistance to children and families who need palliative care. Assistance to children 0 to 5 years old who have feeding issues. To provide necessary services to your child, a Pediatric Team member may consult and work with others including parents, school staff, family physician, other hospitals, agencies and health care providers (including those hired by the family to work with the child) who may also be involved in providing for your child s health, development and general well-being. For example, a team member may interview parents and teachers and gather information about your child s medical condition from various other agencies and health care providers in order to assess your child's needs. This may also involve taking photographs for illustration purposes, doing formal and informal assessments and trialing specialized equipment. Based on the assessment, a child-specific care plan is developed to address his or her needs. We may share this care plan with and offer training to parents, teachers and other care providers who may also be involved in caring for your child. Where a child may require specialized equipment, we may also assist parents in obtaining funding for such equipment through programs offered by various government or other agencies, such as the Ministry of Children and Family Development or Ministry of Healthy Living and Sport. To do so, we may have to complete necessary application forms and provide these agencies with the required information about your child in order for him or her to receive benefits under such programs. By signing below, you authorize VCH to collect, use and share information about you and/or your child as described above for purposes of the Pediatric Team providing services to you and/or your child. VCH collects, uses and shares personal information only in accordance with the BC Freedom of Information and Protection of Privacy Act. You may withdraw your consent at any time by contacting the VCH Vancouver Regional Pediatric Team. Signature Print Name of Parent/Guardian Date Address Please contact the VCH Information Privacy Office at (604) or privacy@vch.ca if you have any questions about your privacy.

2 VANCOUVER REGIONAL PEDIATRIC TEAM rd 2110 West 43 Avenue, Vancouver, BC Canada V6M 2E1 Date: REQUEST FOR CONSULTATION REFERRAL to Occupational Therapy and/or Physiotherapy REFERRED BY: NAME & AGENCY AT REQUEST OF Primary School Contact: Phone: Best time to contact: STUDENT INFORMATION: Student Name: Birth date: Address: Personal Health Number (required): Aboriginal status: Yes No Unknown Home Phone: Gender: M F Parent(s) or Guardian: List address if different from above: Phone: (H) (W) Language(s) at home: Relationship to student: Interpreter is required: Yes / No Student is: Verbal Non-Verbal SCHOOL PERSONNEL INVOLVED: School: School Phone: Grade/Program: Teacher: Resource Teacher: Support Worker: SLP: Psychologist: DIAGNOSIS/DESIGNATION: (If not yet diagnosed, please explain) Does the child have an IEP? Yes No Is the School Based Team aware of this referral? Yes No *If yes to the above, please attach copy of IEP and/or PRIS. Services for the upcoming school year will not begin until the complete referral package is processed School Consent and VRPT Consent MUST be completed for services to begin If available, attach copies of report(s) from specialists or agencies involved *IEP Individual Education Plan PRIS Pre-referral Intervention Strategies form Rev. 08/2010 Page 1 of 2

3 Student Name: REFERRAL REASON(S): Please all that apply & describe in detail on a separate piece of paper if needed. If appropriate, complete the requested addendums and collaborate with the student s family. Safety: (i.e. falling, choking) Feeding: Please provide details if applicable Fine Motor Skills: Please complete Fine Motor Addendum AND provide printing/writing sample. Sensory: Please complete the Short Sensory Profile if applicable. Mobility/Access: The child has difficulty inside classroom outside classroom on playground in P.E. Please complete Gross Motor Addendum Equipment Needs: Please list any specialized equipment the child currently uses: Please list any additional equipment required for the child within the school environment (i.e. toileting, self care, assistive technology, adapted seating): If this child is NOT performing at grade level in all curriculum areas, please give details/examples about current areas being modified (attach IEP and/or PRIS if applicable): What are the primary concerns and goals of the family? What are the primary concerns of the school and what specifically would you like to see come out of this consultation? PRIOR TO FAXING: Please ensure you attach the following: School Consent VRPT Consent Other report(s) All applicable addendum(s) Rev. 08/2010 Page 2 of 2

4 Please circle or answer. SITTING POSTURE: VANCOUVER REGIONAL PEDIATRIC TEAM 2110 West 43 rd Avenue, Vancouver, BC Canada V6M 2E1 FINE MOTOR ADDENDUM Child s Name: twists or falls out of chair slumps fidgets in seat sits too far from desk tilts chair holds head too close to work leans on arm/hand uses one or both hands to support sitting Other: PENCIL GRASP: Other: COLOURING/DRAWING/WRITING: 1. right handed left handed switches inconsistent 2. hand tires hand hurts pencil held tightly pencil held loosely presses too hard doesn t press hard enough 3. Does the child engage in arts and crafts willingly? (Y/N) 4. Does the child colour within the lines? (Y/N) Do they colour using only one type of stroke? (Y/N) 5. Which of the following can the child draw? 6. Have child Draw-a-person at the back of this sheet CUTTING: 1. Can the child hold and manage scissors? (Y/N) Can the child make simple snips? (Y/N) 2. Can the child cut on a line (pencil line)? (Y/N) If no, how thick does the line need to be? 3. Can the child cut: on a straight line on a curved line corners and angles mixed curves and angles FINE MOTOR TASKS: circle the activities that are difficult for the child. build with lego lace beads put coins in slot stack blocks spin a top do up buttons do up zippers tie laces open lunch packages turn up glue stick WRITTEN WORK: Provide a copy of child s free writing sample and/or have child copy the following sentence onto lined paper The quick brown fox jumps over the lazy dog. 1. Can the child recognize letters? all none some 2. Letters formed in an efficient manner (top to bottom, left to right)? (Y/N) 8. Writing Speed: slow average fast Work completed in allotted time? (Y/N) 9. Difficulty copying from: board text both OTHER CONCERNS and/or STRATEGIES ATTEMPTED: Rev. 08/2010

5 VANCOUVER REGIONAL PEDIATRIC TEAM 2110 West 43 rd Avenue, Vancouver, BC Canada V6M 2E1 GROSS MOTOR ADDENDUM SAFETY ISSUES: Please indicate if observed: Y N 1. Difficulty or fear of stairs 2. Decreased awareness of surroundings (Examples of decreased environmental awareness include not being aware of flying balls in gym class or not being aware of walking into the path of a moving swing.) Explain: 3. Impulsive actions Explain: 4. History of falling or loss of balance. Please have the following section completed by P.E. teacher or staff member who most observes the following: 1. Seems weaker than other children his or her age. 2. Fatigues quicker than other children. 3. Appears stiff, awkward in his or her movements. 4. Difficulty getting up from sitting or floor. 5. Fear of going on equipment (i.e. playground). 6. Poor balance. 7. Difficulty hopping, jumping, skipping. 8. Poor ball skills (throw, catch, kick). 9. Toe walking 10. Appears generally clumsy. Please indicate if observed: Y N Additional Comments: Rev. 08/2010