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Brief Psycho-Education Telephone Consult
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:
2.
Diagnosed disabilities/illnesses/disorders:
3.
Previous psychological treatment/input:
4.
Who else lives in the home with the child/teen:
1:
2:
3:
4:
5:
6:
7:
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):
6.
Brief info about the child/teen's peer/friend connections and quality:
7.
Brief info about the child/teen's learning/school abilities/functioning:
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):
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):
1.
2.
3.
10.
What 3 or 4 factors are contributing or causing the problems to occur:
1.
2.
3.
4.
11.
What have you tried and how has this worked/not worked:
12.
For the approaches which have NOT worked, what are the reasons they have they failed/not worked consistently?
13.
What are the child/teen's strengths or positives about the situation?
14.
Please write 3 or 4 specific questions would you most like the answers to now:
1.
2.
3.
4.
15.
What else would you like to gain from this telephone consult:
*
16.
Please indicate your acceptance of the following,
I understand and accept that:
(Required.)
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
Current Progress,
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