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James D. Chandler, MD FRCPC

General Psychiatry

Yarmouth Professional Building

615 Main St. Suite 315

Yarmouth, NS B5A 1K1 Phone 902-742-6661


Questionnaire for Non-Emergent Child and Adolescent Referrals to Dr. Jim Chandler

You can send this one of three ways. The fastest and most reliable is email.

1.mail this to our office address above.

2. email it to us. Just copy this into a word processing program and send it as an attachment or in the text.  The email address is drjameschandlermd@gmail.com

3. Fax it to us  at742-5303

 

 

Child's Name__________________________________________________________________________________Date of Birth_________________________________________ Sex_________

Primary address where Child lives_________________________________________________________________________________________                         

 

Caregivers and how to find them - (this includes parents, stepparents, agencies( if they are the legal guardian)

Name of Caregiver

Relationship to child

Is this a legal guardian?

Mobile phone

work phone

homephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

. Feel free to use another sheet of paper if that is easier.

1.     Please briefly describe the type of problem your Child has. Include how long it has been going on and how it has affected your child at home, with his friends, and at school.

 

 

 

 

 

 

2.     Who has assessed this child so far? What was their diagnosis? What Treatment did they provide? What was the result of the treatment?

 

 

3.     Has the child taken medications? What was the drug? What Dose? How long? What side Effects? Did it work? How well?

 

 

 

 

 

 

 

4.     Does anyone in your family have a similar problem or other psychiatric problems?

 

 

5.     What medical problems does your child have?

 

 

6.     Has this child been in trouble with the law? Does he have a problem with substance abuse?

 

 

7.     Is Family and Children Services involved?

 

 

8.     Has your child attempted suicide? If yes, describe the details.

 

 

9.     Does your child hear voices or see things?

 

 

10. Has your child been abused either emotionally, physically or sexually?