Child And Adolescent Mental Health Assessment
ADVERTISEMENT
1
2
3Child & Adolescent Mental Health Assessment and Treatment Referral
(Edmonton Zone)
Child & Adolescent Mental Health Intake Service is not a Crisis Service. If you believe this child/youth is at
imminent risk, call the Children’s Mental Health Crisis Line at 780-427-4491 in Edmonton, or your local crisis
line.
NOTE – If a psychiatrist is currently involved with this child/youth, an internal referral must be submitted by
psychiatrist. Please request referral through his/her psychiatrist.
Send completed referral by fax to 780-413-4728 or by mail to Child and Adolescent Mental Health Intake
Services, 2020, 9499 - 137 Avenue Edmonton, AB T5E 5R8. For information please call 780-342-2701.
As part of the referral process, a legal guardian or mature minor will be asked to participate in a telephone
interview that will take approximately 60 minutes. Please indicate name and phone number of person to
contact. Name
Phone #
.
_______________________________________________________
_______________________
Date
Referred by
(yyyy-Mon-dd)
Phone
Fax
Relationship to child / youth
Signature
Name of child / youth
(middle)
(last)
(first)
Other names child / youth is known by
Address of primary residence
Phone
City
Province
Postal Code
Personal Health Care Number
Date of Birth
Age
(yyyy-Mon-dd)
£ Male
£ Female
Grade
School
Legal guardian(s)
First name
Last name
Relationship to child / youth Phone
Phone
(home)
(cell/work)
First name
Last name
Relationship to child / youth Phone
Phone
(home)
(cell/work)
Current legal status
(note: documents may be requested)
£ Joint custody
£ Sole custody
£ Custody not yet established
Who lives in the child / youth’s home:
All legal guardians are aware of and in agreement with referral
Language(s) spoken at home
£ Yes
£ No
Page 1 of 3
18344(2013-01)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical