「心泉」- 心理健康前期評估服務轉介表HK Well’s Mental Health Pre-Screening Assessment Referral Form
由轉介人填寫(轉介人資必須為教師、註校護士、特殊學習需要專責人員(SENCO、醫生、社會工作者、受戒牧師、傳道人、教育心理學家或心理學家)To be completed by the referrer(limiting to teachers, school nurses, SENCO,  general practitioners, social workers, ordained ministers, lay pastors, education psychologists and clinical psychologists)
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Email *
姓名Name *
服務機構Organisation *
職位Position *
日期Date *
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DD
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轉介兒童之姓名Name of the child you are referring *
你聯絡之相關家長資料(姓名及電話)Your contact point with the child's family (Name and tel no.) *
你是否曾與家長面談Have you met the parent(s)? *
請簡述轉介原因 Briefly describe the reasons for this referral to mental health pre-screening session: *
在心理健康前期評估服務過程和之後,你會繼續跟進這個家庭嗎?Will you offer follow up to this family during and after the pr-screening session? *
聯絡方法Contact *
A copy of your responses will be emailed to the address you provided.
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