OOHC Pre-Assessment Questionnaire

Please answer the questions with as much information as you can and supply any relevant documents related to your young person and any reports of assessments stated in question 6.

Contact Organisation(Required)

Contact Name(Required)

Contact Email Address(Required)

Young Person's Name(Required)

Date of Birth(Required)

Address(Required)

Child's Medicare Number(Required)

Please include card number and their number position on the card.

Carer Name(s)(Required)

Person Responsible for Organising Appointments (Provide Contact Number and Email)(Required)

Carer Location (if different to child)

Is English their first language?

If not, please indicate whether parent or child will require a translator for assessment purposes.

1. What are the reasons for requesting our services; What particular questions do you need answering with our mental health assessment and therapeutic interventions? What concerns do you have about the child(ren) and/or parent(s)?

2. What order are they are on, if any?

3. What is the child’s and family’s current living situation? (Resi; Foster carer; parent or kinship; Is the placement stable and safe at this moment? Is it interim or emergency?) Who is involved in the family?

4. What is the child’s current school or work situation? Are there concerns about their engagement?

5. What organisations manage the child(ren)’s day to day life? And who makes up their care team? (E.g., DFFH, Resi, School, NDIS, etc.)

6. What services are already involved in the child(ren)’s life and/or parent(s) life? (E.g., Paediatrician; GP; individual therapist; family therapist; OT; Speech)

7. What assessments have already been completed for child(ren) and parent(s)? (Eg., Cognitive Assessment, ASD Assessment, Mental Health Assessments, OT, Speech, Medical, etc.)

File

Max. file size: 128 MB.

8. Are there any known diagnoses for child(ren) and parent(s)? (If yes, please specify).

9. Does the child(ren)/parent(s) already take medications? Who manages these? (If yes, please specify below or attach current medication list)

File

Max. file size: 128 MB.

10. What is the willingness of the child/family to be involved with an assessment at our service?

11. Are there any logistical issues getting to the assessment (eg. transport issues)? Who will be bringing the child(ren)?

12. Will there be any issues or risks around assessment at our offices? (Consider clinician safety. Are there any safety plans already in place or plans you would recommend? ) (If yes, please specify below)

13. Are there any mental health risks we need to know about (suicide; self harm; substances; sexualised behaviours; aggression; family violence; parental substance abuse) (If yes, please specify below)

14. If the referral were to go ahead who would be the contact person to send invoices to? (This can speed up the assessment process, thank you.)

OOHC Pre-Assessment Questionnaire

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