School related difficulties: What are the child’s current mental health issues/concerns? Mood (irritability, crying, feeling sad) Recent stressful/ traumatic event Anxiety (avoidance, phobias, separation) Somatic complaints -no physical cause Sleep (routine, hygiene, disrupted) Attention/ Concentration Appetite (increase, decrease) Academic performance Energy (decrease, hyperactivity) Social difficulties Toileting (encopresis, enuresis, bed wetting) Behavioural issues Further information: Treatment Goals (E.g. what will be different/improved as a result of this referral?) Issue Goal Client Consent: I (the parent /carer)______________________ consent to this Child Treatment Plan to proceed and I agree to this information to be recorded in my child’s medical files and being shared between the GP, the Allied Mental Health Professional and Others to whom referred, to assist in the management of my child’s health care. I ______________________ have discussed the proposed referral with the patient and am satisfied they understand the proposed uses and disclosures and has provided their informed consent to these. Signature: Doctor Signature: Date:
School related difficulties: What are the child’s current mental health issues/concerns? Mood (irritability, crying, feeling sad) Anxiety (avoidance, phobias, separation) Sleep (routine, hygiene, disrupted) Appetite (increase, decrease) Energy (decrease, hyperactivity) Toileting (encopresis, enuresis, bed wetting) Recent stressful/ traumatic event Somatic complaints -no physical cause Attention/ Concentration Academic performance Social difficulties Behavioural issues Further information: Treatment Goals (E.g. what will be different/improved as a result of this referral?) Issue Goal Client Consent: I (the parent /carer)______________________ consent to this Child Treatment Plan to proceed and I agree to this information to be recorded in my child’s medical files and being shared between the GP, the Allied Mental Health Professional and Others to whom referred, to assist in the management of my child’s health care. I ______________________ have discussed the proposed referral with the patient and am satisfied they understand the proposed uses and disclosures and has provided their informed consent to these. Signature: Doctor Signature: Date:
ATAPS-Child-Treatment-Plan_Word-(master).docx