Brief Psycho-Education Telephone Consult

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* 1. Please provide the Following:

Your Name:

Your Relationship to the Child/Teen:

Street Address (of the child/teen of concern):

City/Town:

State/Province:

Postal Code:

Name (of the child/teen of concern):

Date of Birth (of the child/teen of concern):

Best Contact Phone Number:

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* 2. Diagnosed disabilities/illnesses/disorders:

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* 3. Previous psychological treatment/input:

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* 4. Who else lives in the home with the child/teen:

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* 5. Other important family members in the child/teen's life (include info about both parents/caregivers if not listed above, and how much contact the child/teen has with them):

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* 6. Brief info about the child/teen's peer/friend connections and quality:

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* 7. Brief info about the child/teen's learning/school abilities/functioning:

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* 8. Write a description of the central problem/concern that is happening right now (please include specific information about examples of problem behaviours and problem feelings/thoughts):

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* 9. Write a few specific times or situations for when the problems/concerns occur or when you notice them happening? (please note, this is a tough question for some, as it can feel like it happens "all the time" or "randomly" but it is important to try to identify at least some triggers):

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* 10. What 3 or 4 factors are contributing or causing the problems to occur:

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* 11. What have you tried and how has this worked/not worked:

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* 12. For the approaches which have NOT worked, what are the reasons they have they failed/not worked consistently?

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* 13. What are the child/teen's strengths or positives about the situation?

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* 14. Please write 3 or 4 specific questions would you most like the answers to now:

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* 15. What else would you like to gain from this telephone consult:

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* 16. Please indicate your acceptance of the following,
I understand and accept that:

This consultation is a "one off" consultation and in the case that ongoing support and therapy is required, I will seek this from other service providers.

This telephone consultation is a brief psycho-education intervention and not a therapy session and therefore there is not the capacity/opportunity for me to extensively discuss specifics of the situation and is primarily an opportunity to hear/receive brief recommendations and overview of my options

This telephone consultation is for parents/caregivers only and children/teens must not be present

This telephone consultation is not suitable for parents/caregivers of children/teens with significant safety concerns or those seeking information/advice about legal/custody/access or family court matters

All information I provide is confidential EXCEPT in the case of suspected child abuse, significant safety issues for the child/teen

My information is collected and stored securely in accordance with all current legislation

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* 1. Please provide the Following:

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* 2. Diagnosed disabilities/illnesses/disorders:

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* 3. Previous psychological treatment/input:

Question Title

* 4. Who else lives in the home with the child/teen:

Question Title

* 5. Other important family members in the child/teen's life (include info about both parents/caregivers if not listed above, and how much contact the child/teen has with them):

Question Title

* 6. Brief info about the child/teen's peer/friend connections and quality:

Question Title

* 7. Brief info about the child/teen's learning/school abilities/functioning:

Question Title

* 8. Write a description of the central problem/concern that is happening right now (please include specific information about examples of problem behaviours and problem feelings/thoughts):

Question Title

* 9. Write a few specific times or situations for when the problems/concerns occur or when you notice them happening? (please note, this is a tough question for some, as it can feel like it happens "all the time" or "randomly" but it is important to try to identify at least some triggers):

Question Title

* 10. What 3 or 4 factors are contributing or causing the problems to occur:

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* 11. What have you tried and how has this worked/not worked:

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* 12. For the approaches which have NOT worked, what are the reasons they have they failed/not worked consistently?

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* 13. What are the child/teen's strengths or positives about the situation?

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* 14. Please write 3 or 4 specific questions would you most like the answers to now:

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* 15. What else would you like to gain from this telephone consult:

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* 16. Please indicate your acceptance of the following,I understand and accept that:

* 16. Please indicate your acceptance of the following,
I understand and accept that: