FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

Child and Youth Health Management Plan - Team Case Conference

RE: <Insert Patient Initials>
DOB: <PtDoB>

Date and time of case conference:  

Conference participants: Consider inviting patient, parent, carer, Child Safety Officer, allied health, Paediatrician, Aboriginal Health Service/Cultural Advisor, mental health clinician, school, Foster & Kinship/Residential agency worker.
Name | Service | Role
Other Services involved:

Please consider relevancy of information in the best interest of the child

Previous assessments, diagnoses or medical history (include dates):  
<PMHAll>

Personal information about the child/young person (consider positive aspects, interests, things that are important to them, progress):  

Health Assessment attached:  YES / NO

Current Medications:
<CurrentRx>

Consider 'over-the-counter' and 'natural' drugs and supplements:

Goals of the child/young person, family, carer:
Progress since previous case conference (if applicable) previously identified actions and progress:

Important issues and concerns

Actions

Who (GP, parent, carer, allied health, specialist, school)

Timeframe
Indicate if completed and document any barriers to completion

Medication: | | |
Physical concerns / disability: | | |
Mental Health / behavioural: | | |
Learning / Education & other developmental: | | |
Cultural connectedness: | | |
Other: | | |

Verbal agreement to the above Health Management Plan by parent/carer/Child Safety Officer:   YES / NO

Duration of case conference: | Doctor in attendance: | Signature:

Developed by Gold Coast Primary Health Network                                                                                                                                                                                                                         November  2019