Operations Guideline on

Student Mental Health

Support Scheme
「醫教社同心協作計劃」指引

Version Effective Date

2.0 1 September 2018

Author Task Force on Student Mental Health Support Scheme

Distribution List Task Force on Student Mental Health Support Scheme

[including representatives of Food and Health Bureau
(FHB); Hospital Authority (HA); Education Bureau (EDB);
Social Welfare Department (SWD); and NGOs]; Schools
through EDB; School Social Work Service, Integrated
Children and Youth Services Centres (ICYSCs), Integrated
Family Service Centres (IFSCs), Integrated Services Centres
(ISCs), Medical Social Services Units (MSSUs) and Family
and Child Protective Services Units (FCPSUs) participating
in the Student Mental Health Scheme, or any other relevant
social welfare service units and NGOs through SWD; HA
Co-ordinating Committee (Psychiatry) and HA Task group
on Student Mental Health Support Scheme through
Integrated Care Programs Department of HAHO
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Table of Contents
Statement of Intent ................................................................................................................................................................. 7

I. Background ................................................................................................................................................................... 8

II. Principles of Care and the Stepped Care Model for Children and Adolescents with Mental Health Needs ........ 9

III. School-based Multi-disciplinary Platform................................................................................................................ 11

1. Scope of Service .......................................................................................................................................... 12

2. Student Recruitment .................................................................................................................................. 14

3. Operation Workflow .................................................................................................................................. 16

4. Annual Screening Exercise ........................................................................................................................ 22

5. Roles and Responsibilities .......................................................................................................................... 26

A. Medical ................................................................................................................................................ 26

B. Education ............................................................................................................................................. 29

C. Social .................................................................................................................................................... 30

6. Documentation ............................................................................................................................................ 32

7. Staff Training .............................................................................................................................................. 34

8. Evaluation ................................................................................................................................................... 37

IV. Abbreviations .............................................................................................................................................................. 38

V. Appendices .................................................................................................................................................................. 39

Appendix 1: Definition of the Three-Tier Service Delivery Model ........................................................................ 39

Appendix 2: Stepped Care Model - Multi-sectoral Participation ........................................................................... 41

Appendix 3: Relevant social and family support services for children and adolescents with mental health needs in
the SMHSS ........................................................................................................................................... 46

Appendix 4: Student Mental Health Support Scheme - Parent/Legal Guardian Consent Form .......................... 47

Appendix 5: Assessment form – HA designated psychiatric nurse ......................................................................... 50

Appendix 6: Assessment form – School personnel ................................................................................................. 54

Appendix 7: Assessment Form -- School Social Work Service ............................................................................... 61

Appendix 8: Integrated Assessment and Care Plan (For Students known to HA C&A Psychiatric Services) ..... 67

Appendix 9: Integrated Assessment and Care Plan (For Students not known to HA C&A Psychiatric Services)73

Appendix 10: Examples of Learning Support Strategies for Students with Mental Health Needs
(in Chinese only) ............................................................................................................................... 79

Appendix 11: Selected Risk and Protective Factors for Mental Health of Children and Adolescents .................. 80
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Appendix 12: Standard brief assessment – HA designated psychiatric nurse (for cases not known to HA C&A
psychiatric services) .......................................................................................................................... 81

Appendix 12A: Standard Assessment Tool (PHQ-9) (for cases of secondary school students only) ..................... 85

Appendix 12B: Standard Assessment Tool (GAD-7) (for cases of secondary school students only) ..................... 86

Appendix 13: Guideline to primary schools on printing and distributing of questionnaire .................................. 87

Appendix 14: Assessment form – HA assistant social work officer (Group Interview) (for cases identified with
subclinical anxiety and/or depressive mood symptoms only and unknown to HA C&A psychiatric
services) ............................................................................................................................................. 88

Appendix 15: Assessment form – HA assistant social work officer (Individual Interview) (for cases identified with
subclincial anxiety and depressive mood symptoms only and unknown to HA C&A psychiatric services) .......... 91

Appendix 16: Parent’s Notice (家長通知書)........................................................................................................... 95

Appendix 17: Parent’s guideline on completing questionnaire (家長填寫問卷指引) .......................................... 96

Appendix 18: Acknowledgement Receipt of Data ................................................................................................... 97

VI. References ................................................................................................................................................................... 98

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Summary of Changes

Change Revision Description Paragraphs / Version Effective

No. Appendix Number Date
with updates
1 Major updates to last version (i.e. Version 1.2 dated 8 December 2017) are summarised
as follows -
A service component on annual Para.12(d) 2.0 1 September 2018
screening exercise added
Content on regular case conference Para.12(e) &
and training updated 12(f)
The support services for students Table in para.
unknown to HA C&A psychiatric 13
service updated
Remark (b) added to elaborate that Remark (b)
some students known to HA general under Table in
adult psychiatric services and/or para. 13
EASY programme are also classified
as “students known to HA” under
SMHSS
Remark (c) updated to make the Remark (c)
presentation clearer under Table in
para. 13
A paragraph on the preparatory work Para. 20
for cases unknown to HA C&A
psychiatric service added
Timeline for document preparation by Para. 22
HA supporting staff is removed to
make it more flexible based on actual
operation.
CP and ASWO added in the paragraph Para. 26
A paragraph added to specify that the Para. 28
multi-disciplinary team will decide on
the responsible personnel for follow-
up actions
A paragraph added to emphasise that Para. 33
intervention should be provided at
school or in the community setting as
far as possible
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Change Revision Description Paragraphs / Version Effective

No. Appendix Number Date
with updates
1 Content under Preparation and Figure III.1 2.0 1 September 2018
Implementation Plan updated
Workflow for cases unknown to HA Figure III.2
CAMHS added
Arrangements, work schedule and Para. 44 to 48
workflow of annual screening Table IV.1
exercise added
Roles and responsibilities of CP and Para. 52 & 53
ASWO added

Roles and responsibilities of Para. 54 & 55

designated school coordinator and
school-based EP beefed up

A summary table listing the Para. 60

documents for SMHSS added
Content on staff training updated Para. 61 to 65

Content on the new evaluation study Para. 66 to 67

updated

Consent form updated Appendix 4

Assessment form - HA designated Appendix 5

psychiatric nurse updated

Assessment from - school personnel Appendix 6

updated

Integrated assessment and care plan Appendix 8

(for students known to HA C&A
psychiatric services) updated, which
amongst others, includes a list of
interventions by respective
professionals/team
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Change Revision Description Paragraphs / Version Effective

No. Appendix Number Date
with updates
1 Integrated assessment and care plan Appendix 9 2.0 1 September 2018
(for students not known to HA C&A
psychiatric services) updated, which
amongst others, includes a list of
interventions by respective
professionals/team

Examples of learning support Appendix 10

strategies for students with mental
health needs updated, with a part on
“Others” added

Standard brief assessment – HA Appendix 12

designated psychiatric nurse for cases
unknown to HA psychiatric services
added

Standard assessment tool (PHQ-9) Appendix 12A

added
Standard assessment tool (GAD-7) Appendix 12B
added
Guideline to primary schools on Appendix 13
printing and distributing of
questionnaire added
Assessment form – HA assistant Appendix 14
social work officer (Group Interview)
added
Assessment form – HA assistant Appendix 15
social work officer (Individual
Interview) added
Parent’s notice added Appendix 16

Parent’s guideline on completing Appendix 17

questionnaire added
Acknowledgement receipt of data Appendix 18
added
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Statement of Intent

The Guideline is designed for the “Student Mental Health Support Scheme” (“SMHSS”)「醫教社同
心協作計劃」, led by the Food and Health Bureau (“FHB”) in collaboration with the Hospital Authority
(“HA”), the Education Bureau (“EDB”) and the Social Welfare Department (“SWD”) to enhance support
for students with mental health needs.

This Guideline should be read by all staff members in medical, education and social sectors who are
involved in the provision of services under the SMHSS.

This Guideline is not intended to be construed as a required practice for individual student care under
the SMHSS, which should be determined on the basis of all the facts and circumstances involved in a
particular case. The Guideline provides guidance over interventional procedures but not clinical practice.
The Guideline is subject to further refinement subject to the development of the SMHSS and views from
relevant stakeholders, service providers and users.

Through this Guideline, we would like to illustrate the operations of the SMHSS which provide multi-
sectoral and multi-disciplinary support on a medical-educational-social collaboration model for the
enhancement of the support services for children and adolescents with mental health needs in the school
setting.
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I. Background

1. According to the World Health Organization (“WHO”), up to 20% of children and adolescents
worldwide suffer from a disabling mental illness and about 4-6% of them are in need of a clinical
intervention. Children and adolescents with mental health problems encounter different levels of
difficulties in coping skills, sense of identity and competence. The spectrum of severity of their
issues is wide, ranging from severely mental illness requiring institutional care to mild mental
conditions with which the patient could live in the community normally.

2. The Convention on the Rights of the Child to safeguard the basic human rights of children came
into force in Hong Kong in 1994. Its provisions continue to apply to Hong Kong after the
establishment of the Hong Kong Special Administrative Region. According to Article 23.1 of the
Convention, states party recognises that a mentally or physically disabled child should enjoy a full
and decent life, in conditions which ensure dignity, promote self-reliance and facilitate the child's
active participation in the community.

3. The Review Committee on Mental Health (“the Review Committee”), chaired by the then Secretary
for Food and Health, was set up in 2013 to study the existing policy on mental health with a view
to mapping out the future direction for development of mental health services in Hong Kong. An
Expert Group on Child and Adolescent Mental Health Service (“the Expert Group”) was set up
under the Review Committee to study services for children and adolescents with mental health needs.

4. Based on the preliminary recommendation of the Expert Group, a Task Force led by the Food and
Health Bureau (“FHB”) in collaboration with the Hospital Authority (“HA”), Education Bureau
(“EDB”) and Social Welfare Department (SWD) spearheaded the implementation of the “Student
Mental Health Support Scheme” (“SMHSS”) (「醫教社同心協作計劃」), in 17 primary and
secondary schools in the catchment areas of Kowloon East Cluster (“KEC”) and Kowloon West
Cluster (“KWC”) in the 2016/17 and the 2017/18 school years based on a medical-educational-
social collaboration model.

5. The above recommendation was included in the Mental Health Review Report which was published
by the Review Committee in April 2017. The full report can be browsed or downloaded by visiting
the website of the Healthcare Planning and Development Office of the FHB at
https://www.fhb.gov.hk/en/press_and_publications/otherinfo/180500_mhr/mhr_background.html.

6. From the 2018/19 school years, the SMHSS will be expanded to more schools with a view to further
enhancing the support for students with mental health needs.
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II. Principles of Care and the Stepped Care Model for Children and
Adolescents with Mental Health Needs

7. The principles of care and the stepped care model for children and adolescents with mental health
needs include -

(a) Comprehensive and child-centred service -- Children and adolescents should have access to
a comprehensive array of services that address their physical, cognitive, emotional, behavioral
and social needs in order to promote positive mental health.
(b) Prevention, early detection and intervention -- Reducing exposure to risk factors and
promoting protective factors, so that children can grow up in an enabling environment that is
conducive to their healthy growth and development.
(c) Integrated service with the involvement of family and school – Home and school are the
primary places where children encounter positive role models and foster social skills
development that are essential to shape their mental health and well-being. Involvement of
family and school with the support of social and health sectors could help the promotion of
mental wellness and management of mental health needs.
(d) Early support in primary care setting – Early support should be given to children and
adolescents with less severe levels of disturbance by providing them with appropriate
consultation, counselling, education, training and support in the primary care setting.
(e) Specialist services for severe and highly complex mental health needs – Specialist services
should give priority to the most seriously disturbed children and those most at risk of developing
severe disturbance.
(f) Smooth service transition – Smooth service transition from one developmental stage to
another should be ensured by addressing the age specific needs of children and adolescents with
ongoing mental health needs.

8. The Mental Health Review Report recommends the adoption of a three-tier stepped care service
model to facilitate cross-sectoral and multi-disciplinary collaboration in the delivery of child and
adolescent mental health services. The emphasis of the model is on promotion of mental wellness,
as well as prevention, early detection and effective intervention of mental health problems. With
multi-sectoral and multi-disciplinary participation, the stepped care model, which is operated in a
dynamic manner, seeks to remove barriers across professional and service boundaries by developing
more cohesive care pathways and strengthening connections among tiers.

Tier 1 – Universal prevention, early detection, intervention and mental health maintenance
Tier 2 – Targeted intervention and important linkage between Tier 1 and Tier 3
Tier 3 – Specialist intervention
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9. The operation definition and the multi-sectoral involvement in the Three-Tier Stepped Care Model
are described in the Appendices. (Appendices 1, 2)

Three-Tier Stepped Care Model

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III. School-based Multi-disciplinary Platform

10. Under the SMHSS, a multi-disciplinary platform is established in each participating school to
enhance the coordination and communication among medical, education and social sectors as well
as the families. The SMHSS aligns with the Stepped Care Model which facilitates cross-sectoral
and multi-disciplinary collaboration to provide Tier-2 intervention for students with mental health
needs at school. Regular meetings will be conducted at schools, through the coordination of the
school personnel, among the professionals of medical, education and social welfare sectors (with
family members if required) to triage newly identified cases according to their urgency and severity.
Care plan of the target students will be delivered in a more cohesive manner to meet the needs of
the children with the right level of intervention. Multi-disciplinary interventions according to their
care plans are provided to help the students resume a normal developmental pathway. Their progress
will be reviewed and necessary adjustment will be made if needed.

School-based multi-disciplinary
platform with regular meetings
to manage students with
mental health needs Social Educational Medical

Designated Designated
Designated
School Social Worker School Teacher
Student Support Nurse
Social workers from
Team Members of MDT
IFSCs/ISCs/MSSUs/
School-based EP C&A psychiatric
FCPSUs for their
and other school services
known cases
teachers Back up by HA
Back up by SWD
Back up by EDB

School–based Multi-disciplinary Collaboration Platform

Implementation & Review of Care Plan

Three-Tier Stepped Care Model

Target Students
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1. Scope of Service

11. Under the SMHSS, a Multi-disciplinary Team is formed in each participating school. The Team
comprises a designated psychiatric nurse from HA, a designated school coordinator and a school
social worker (School Social Worker in secondary schools and Student Guidance Personnel/ Student
Guidance Teacher in primary schools) as the core members who will work closely with the
psychiatric teams of HA, the school-based educational psychologist (EP), relevant teachers and
social workers from relevant social service units such as IFSCs/ISCs/MSSUs/FCPSUs. The
composition of the multi-disciplinary team is tabulated in Table III.1. Relevant multi-disciplinary
team members should encourage the concerned students’ and the parents’ participation in the
intervention process and suitably address questions raised by them for services provided to, or
arrangements made for them under the SMHSS if they express any concerns.

12. The service components include the followings -

(a) Comprehensive assessment (including educational, social and medical aspects as appropriate)
will be provided;
(b) Care plan will be formulated, implemented and monitored by the multi-disciplinary team to
meet the students’ needs with the right level of intervention, reduce the impact of mental health
problems on school and/or family and prevent their escalation to greater or more significant
difficulties;
(c) Multi-disciplinary interventions including medical support, social support and educational
support will be provided with a view to helping children and adolescents resume a normal
developmental pathway;
(d) Annual screening exercise to primary four and secondary one, or a selected form as agreed
with the school, students for primary and secondary schools respectively and subsequent
individual and/or group intervention to students identified to have subclinical anxiety and/or
depressive mood symptoms;
(e) Regular case conferences will be conducted to monitor and review the implementation of the
care plan; and
(f) Training (e.g. structured training courses for professional and supporting staff, school-based
talks, workshops and/or display of exhibition boards) will be provided for school personnel,
social workers of non-governmental organisations (NGOs)/SWD and healthcare workers, and
as and when required, for parents/legal guardians, to strengthen the support for schools, families
and community and enhance their capacity.
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Table III.1
Formation of a Multi-disciplinary Team in each Participating School
Core members:
A designated psychiatric nurse backed up by the MDT from HA to co-chair the multi-
disciplinary platform
A designated school coodinator to co-chair the multi-disciplinary platform
A school social worker supported by the respective NGO

Other members:
+/- School-based EP supported by the respective school sponsoring body or EDB
+/- Social workers from IFSCs, ISCs, FCPSUs or MSSUs (Appendix 3)
+/- Members from the multi-disciplinary psychiatric team of HA
+/- Parents or legal guardians

With secretarial/clerical support by supporting staff of HA

Remarks: If the cases are known to social service units such as IFSCs, ISCs, MSSUs or FCPSUs, having the consent of the
parents/legal guardian with the agreement of the students obatined (Appendix 4), the social workers concerned will be invited to
attend the case conferences to provide inputs on the social care needs of the students and their families. Other members (i.e.
HA case manager, school personnel and students’ parents or legal guardians etc.) may be invited to participate in case conferences
of the school-based multi-disciplinary platform for discussion and engagement on a need basis.
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2. Student Recruitment
Target schools and students

13. A total of 40 primary and secondary schools were invited to participate in the SMHSS. Five HA
clusters with child and adolescent (C&A) psychiatric services (i.e. Hong Kong West Cluster, KEC,
KWC, New Territories (NT) East Cluster and NT West Cluster) will provide support to the 40
schools. The target students and the corresponding support to be provided by the school-based multi-
disciplinary platform are as follows:

Target Students Support to be provided

1. Students known to HA C&A psychiatric services Comprehensive support including multi-
with diagnosed psychiatric disorders (such as disciplinary assessment and intervention,
students with depression, anxiety disorders, formulation of care plan and regular
psychosis, obsessive-compulsive disorder (OCD), review and monitoring.
bipolar disorder, Autism Spectrum Disorders
(ASD), Attention Deficit Hyperactivity Disorder
(AD/HD), with mental health needs or medication
concerns etc.) requiring multi-disciplinary input

2. Students not known to HA C&A psychiatric Support on a need basis including multi-
services but identified to have mental health needs disciplinary assessment and intervention,
(such as depressive mood, anxiety problems etc.) formulation of care plan, liaison with the
corresponding clinical team and review
and monitoring.

Provision of advice and support on a need

basis to teachers and/or social workers in
managing the students e.g. advice for
service matching respective to students’
needs.

Remarks:
(a) All cases discussed in the school-based multi-disciplinary platform must have consent from the
parents/legal guardians. Students should indicate their agreement by signing on the updated consent
form (version 1.0 (2018/19)_20180901) at Appendix 4 [Note: For schools which participated in the
SMHSS in the 2016/17 and 2017/18 school years and had used the earlier version of consent form (i.e.
 P a g e | 15

version 2.0_20170511) should seek fresh consent from parties concerned by arranging them to sign
the updated consent form (version 1.0(2018/19)_20180901) as early as practicable after the
commencement of the 2018/19 school year.].
(b) Some students who may be known to HA general adult psychiatric services and/or Early Assessment
Service for Young People with Early Psychosis (EASY) programme should also be classified as
“students known to HA”. (i.e. Comprehensive support with regular review and monitoring should be
provided.)
(c) Cases presented with pure learning problems would be excluded (e.g., ASD and/or ADHD with pure
learning problems).
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3. Operation Workflow
(Figure III.1)

Student Recruitment
14. The Multi-disciplinary Team will identify potential students requiring support of the SMHSS in
consultation with relevant school personnel (e.g. school principal and guidance teacher) or
professionals (e.g. school-based EPs).

15. The Multi-disciplinary Team will jointly review the student’s profiles and determine the student’s
suitability for enrolment to the SMHSS.

16. If any identifiable personal information of the student is required to be disclosed during the
discussion, prior verbal consent from the parents/legal guardians and secondary students should be
obtained. The school coordinator will arrange to obtain written consent (Appendix 4) from the
parents/legal guardians. Students should indicate their agreement by signing on the updated
consent form (version 1.0(2018/19)_20180901) at Appendix 4. [Note: For schools which have
used the earlier version of consent form should arrange parties concerned to sign the updated
consent form (version 1.0(2018/19)_20180901) as early as practicable during the pilot period.].

17. Communication among core members of the Multi-disciplinary Team can be done by various
channels. Working meetings can be arranged to consider the suitability of recruiting the student
concerned and prioritise students into the SMHSS.

18. For students who are considered more suitable to receive other appropriate services instead of
support of the SMHSS, the Multi-disciplinary Team will discuss follow up actions for the students
as deemed necessary (e.g. IFSCs, ISCs, MSSUs (Appendix 3), C&A psychiatric services etc. )

Preparatory Work
19. The Multi-disciplinary Team will collect information, including the background information and
assesssment data by professionals from different sectors, for the completion of respective
assessment forms (Appendices 5,6,7,12) in around 4 weeks’ time to identify the student’s needs in different
areas. Where practicable and with data subjects’ consent, information sharing among multi-
disciplinary team members concerned could facilitate data collection and minimise disturbances to
parents/legal guardians and/or students for responding similar questions asked by different
professionals.

20. For cases not known to HA C&A psychiatric services, the designated psychiatric nurse of HA will
conduct a standard brief assessment for the students (Appendices 12) and suggest further management by
different disciplines (e.g. clinical psychologists (CPs), assistant social work officers (ASWOs) or
the designated psychiatric nurses) (Fig. III.2)
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21. If confirmed that the case is being followed up by any social service unit, the school social worker
will invite the responsible social worker of the social service unit to attend the case conference as
appropriate.

22. The supporting staff from HA will help compile the documents into an individual student folder
which should be placed in the designated area in school office, where only designated personnel
could have access to, for the Multi-disciplinary Team’s reference around 1 week before the case
conference. If the documents are not yet ready for compilation (e.g. the documents are still being
updated due to intervention / support being provided to the student concerned within the week before
the case conference, etc.), the supporting staff may help compile the documents into the student
folder as early as possible after the updated documents are available.

Case Conferences of the School-based Multi-disciplinary Platform

23. The Multi-disciplinary Team will conduct case conferences at school regularly for case assessment,
prioritisation and review.

24. The case conferences will be implemented with composition as stipulated in Table III.1.

25. Members of the case conference should be vigilant in ensuring confidentiality of the students’ and/or
the parents’/legal guardians’ information. To start each case conference, the co-chairmen should
remind members to keep confidentiality of case information and the requirement of sharing
information on a need-to-know basis.

26. The Multi-disciplinary Team will provide appropriate support as mentioned in the table of “Roles
and Responsibilities” in paragraphs 50 to 55 of this guideline for the concerned cases, subject to the
joint decision with the social worker of the relevant social service unit (if the case is known to IFSC,
ISC, MSSU or FCPSU), the school-based EP, the CPs and/or the ASWOs (who are involved in case
conferences on a need basis) who attend the case conferences.

27. The Multi-disciplinary Team will formulate the Integrated Assessment and Care Plan (Appendix
8/9) for each student at the end of the case conference to guide the follow up action and progress

monitoring.

28. The Multi-disciplinary Team will decide on the responsible personnel, on a case-by-case basis, to
communicate with the parents/legal guardians on the care plan and the follow up action to encourage
parents’/legal guardians’ participation in the intervention process.

29. Students with family issues can be referred to the relevant IFSCs, ISCs, FCPSUs, MSSUs or other
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relevant social service units for follow-up in accordance with their respective service ambits with
consent obtained from parents/legal guardians and the students via the school social workers. The
designated school social workers would help coordinate and link up with the community social
services for the students and their families.

30. Family members, legal guardians or relevant stakeholders (e.g. HA case manager, etc.) may be
invited to join the case conference for sharing and engagement on a need basis.

31. Some examples of the learning support strategies for students with mental health needs are listed in
Appendix (Appendix 10).

Implementation of Care Plan

32. Professionals from different sectors will carry out appropriate interventions according to the
Integrated Assessment and Care Plan (Appendix 8/9).

33. To facilitate cross-sectoral and multi-disciplinary collaboration to provide Tier-2 intervention and
to foster capacity building among different professional personnel to support for students with
mental health needs at school, interventions, relevant support services and activities as well as
follow-up actions should, to a large extent, be conduct at school or in the community setting as far
as possible.

34. The respective professionals in the Multi-disciplinary Team will continuously monitor the
progress and adjust the Integrated Assessment and Care Plan as appropriate. Progress update
among sectors can be done by various channels such as case conference, routine communications
among multi-disciplinary team members, small group meetings etc.

Case Review
35. Condition of each target student who is known to HA C&A psychiatric services will be reviewed in
the case conference at least twice a year.

36. Condition of each target student who is not known to HA C&A psychiatric services will be discussed
and reviewed subject to case conference decision on the follow-up plan.

37. For students with complex needs, additional case conferences could be arranged on a need basis.

Information on Assistance on Mental Health Related Issues

38. During office hours, the designated school coordinator can contact the designated psychiatric nurse
for any advice on mental health related issues.
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39. There is a HA 24-hour psychiatric advisory hotline -2466 7350- , namely “Mental Health Direct”
醫院管理局精神健康專線 to provide advisory service and information on mental health related
issues.

40. There is an “EASY hotline” 「思覺失調」熱線 -2928 3283- for enquiry for mental illnesses related
to psychotic symptoms.

41. School personnel should continue to follow their school guidelines for crisis management to handle
emergency.

Procedure for Releasing Information from the School-based Multi-disciplinary Platform

42. Any non-designated person (e.g. students or students’ parents/ legal guardians) who would like to
obtain any reports or information from the school-based multi-disciplinary platform should follow
the formal application procedure via the school. Information to be released should be agreed by all
the three sectors (i.e. medical, education and social) of the school platform.

Assistance for Students with Other Needs ( not eligible to the SMHSS)
43. For students with other needs, they will be referred to appropriate service units or supporting
services if applicable with the consent obatined from the parents/legal guardians and the students.
For examples:

(a) For students only with learning problems, they can be followed up by the School Support
Team.
(b) For students with family problems or financial issues, they can be referred to the IFSC, ISC,
MSSU or Social Security Field Unit for appropriate follow-up services via school social
workers. (Appendix 3)
(c) For students with other medical issues, they can be diverted to appropriate medical units for
further assessment via the school personnel.
(d) For students with suspected child abuse, they can be referred to FCPSU for investigation via
school personnel, social workers or medical professionals.
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Figure III.1

1. Student Recruitment
Students Identification
Identify potential students by the Multi-disciplinary Team in consultation of relevant school personnel or professionals (e.g.
school-based EP)

For students Relevant service

Student Selection suitable for matching
The Multi-disciplinary Team to review the profiles of the students and jointly determine other services The Multi-disciplinary
the suitability to join the SMHSS; the school coordinator to obtain verbal consent from Team to discuss other
the parents/legal guardians and secondary students in advance if any identifiable appropriate services
personal information of the student is required to be disclosed. or follow up
No
For selected students
2. Preparatory Work
Obtain Parent/Legal Guardian Consent
Obtain written consent from the parents/legal guardians vide Consent Form (version 1.0(2018/19)_20180901)
with student’s agreement
With mental health needs
[Note: For schools that have used the earlier version of Consent Form should arrange parties concerned to sign the updated Consent Form
(version 1.0(2018/19)_20180901) as early as practicable.]

Yes

Preparation
1. Collect information and preliminary assessment by respective disciplines in 4 weeks after the written consent of
parents/legal guardians has been obtained
2. With consent from the parent/legal guardian and agreement of the student, invite the social worker from the relevant social
service unit, such as IFSC, ISC, MSSU or FCPSU, to attend the case conferences if it is their known case as appropriate.
3. Compile documents by HA supporting staff and place the folder at the designated area in school office around 1 week before
the case conference, or as early as possible after the updated documents are available.
4. For students known to HA: The designated psychiatric nurse will conduct the Clinical Assessment Form. (Appendix 5)
For students NOT known to HA: The designated psychiatric nurse will conduct the Standard Brief Assessment Form.
(Appendix 12)

3. School-based multi-disciplinary platform ̶ Case Conference

Formulation of Integrated Assessment and Care Plan
1.Conduct case conference regularly
2. Formulate the Integrated Assessment and Care Plan for each student under the SMHSS for action and progress monitoring

4. Implementation of Care Plan

Implementation of Care Plan
1. Provide appropriate support, care and services according to the care plan by the responsible units
2. The activities and follow-up actions should, to a great extent, be conducted at school or in the community setting

Progress Monitoring
1. Monitor the progress and adjust the Integrated Assessment and Care Plan as appropriate
2. Update among sectors by various channels as appropriate
3. Feedback to the school-based multi-disciplinary platform if necessary

5. Case Review −Case Conference

Review and Evaluation
Evaluation and review the outcomes and refine the Integrated Assessment and Care Plan as appropriate
For students known to HA: Each student will be reviewed at least twice a year (around once in each semester)
For students NOT known to HA: Each student will be reviewed subject to the decision of the case conference

Figure III.2
Workflow of cases unknown to CAMHS
Students do not give
consent to join SMHSS
Explore other suitable
resources to support the
students by school
Students requiring
further follow up after
annual screening
exercise and/or
intervention by ASWOs
Assessment &
intervention by
CPs
3. School-based multi-disciplinary platform ̶ Case Conference
Multi-disciplinary
team support
(e.g. teachers,
school social
4. Implementation of Care Plan
workers, EPs, etc.)
P a g e | 21
1. Student Recruitment
Students unknown to HA C&A psychiatric services
but identified with mental health needs
2. Preparatory Work
Refer to SMHSS and seek parent/legal
guardians’ and students’ consent by schools
Standard brief assessment by designated psychiatric nurses
(Appendix 12)
(e.g. on behavioral/eating problems, clinical anxiety or
depression)
[+/- standard assessment tools (e.g. PHQ-9(Appendix 12A), GAD-
7(Appendix 12B)) (for secondary school students only)]
Assessment & Assessment &
Cases step up/ intervention by Cases step up/ intervention by
down as needed psychiatric nurses down as needed ASWOs
All cases reported to case conferences
5. Case Review −Case Conference
Follow up as appropriate
 P a g e | 22

4. Annual Screening Exercise

(Figure IV.1)

44. From the 2018/19 school year, ASWOs and supporting staff of HA will coordinate with school
personnel and school social worker to conduct an annual screening exercise to primary four and
secondary one (or a selected form as agreed with the school) students for participating primary and
secondary schools respectively.

45. The annual screening exercise employs an evidence-based assessment tool, Spence Children’s
Anxiety Scale, with an aim at early identification of community children and adolescents with
anxious and/or depressive mood problems through a proactive approach.

46. For the annual screening exercise in primary school, parents/legal guardians will be invited to
complete the parent version questionnaire in paper form (Appendix 13). While in secondary school,
students will be invited to complete the child version questionnaire online.

47. For students identified with subclinical anxiety and/or depressive mood symptoms, the ASWOs,
will conduct a face-to-face group/individual interview with the students and/or the parents/legal
guardians for further assessment. (Appendix 14/15)

48. For students screened with subclinical anxiety and/or depressive mood symptoms, the ASWOs will
coordinate with relevant school personnel and/or school social worker to provide brief and low
intensity intervention to the students. Interventions include psycho-educational activities to students
and/or their parents/legal guardians, anxiety management group and/or brief intervention (either
individual/day program/workshop). To facilitate cross-sectoral and multi-disciplinary collaboration,
relevant school personnel and/or school social worker will be invited to sit-in the assessment and
follow up sessions provided by ASWOs.

49. The work schedule of the annual screening exercise and the subsequent individual and/or group
intervention will last for around four months. For the first time, ASWOs and relevant school
personnel and/or school social worker should communicate and discuss the work schedule after the
school year commences in September. Afterwards on an annual basis, they are advised to
communicate and discuss the work schedule of the coming school year around July (i.e. before the
end of the current school year).
 P a g e | 23

Table IV. 1
Date Work Schedule
Week 0 - Liaise with school to confirm the following dates and time:
 School-based screening to parent/legal guardian (for primary school) or students (for
secondary school)
 Face-to-face group/individual interview (簡介會) with parents/legal guardians and
students (for primary school) or students (for secondary school)
 6 sessions’ group intervention/day programme/workshop
Week 1 Finalise work plan and “Parent’s Notice (家長通知書)” (Appendix 16) with school
Week 2 - School to print and/or distribute
 Parent’s Notice (家長通知書) (Appendix 16)
 Questionnaire and “Parent’s guideline on completing questionnaire” (家長填寫問
卷指引) (Appendix 17) to parent/legal guardian (for primary school)
 Log-in guideline and students’ password to complete on-line screening (for
secondary school)
Week 3 - School to provide an electronic student’s list to ASWO
- School to deliver the completed questionnaires and “Acknowledgement Receipt of
Data” form (Appendix 18) to ASWO (for primary school)
- Data entry of questionnaire
Week 4 - ASWO to provide a list of students with elevated scores to school
- School to identify SEN students from the list provided by ASWO
- School to seek consent from parents/legal guardians and/or students to join SMHSS
- School to send invitation to the final list of students with subclinical scores to attend
group/individual interview (簡介會)
- ASWO to inform school that some students with elevated score (suspected mental
health concerns) might need mental health service and/or to be brought up to SMHSS
(also advise on service matching for social or educational needs)
Week 5 - ASWO to confirm group/individual interview attendance list with school
Week 6 – 7 - ASWO to conduct group/individual interview(s) ( 簡 介 會 ) with students and/or
parents/legal guardians (Appendix 14/15)
- ASWO to have case discussion with CP to identify potential candidates to join
group/individual intervention/day programme/workshop by ASWO
Week 8 - ASWO to provide a list of potential candidates to school
- School to send invitation to parent/legal guardian and/or student to attend the
group/individual intervention/day programme/workshop by ASWO
- School to confirm attendance list with ASWO
Week 9 – 14 - Group/individual intervention/day program/workshop implementation
 P a g e | 24

Figure IV.1

Workflow of annual screening exercise in schools participating in SMHSS

Send invitation and screening form
to F.1/P.4 students through school

Students/Parents/Legal
Guardians do not give
consent for the screening

Screening by an evidence-based assessment tool

(for anxiety +/- depressive mood symptoms)

Students screened with Students screened without

clinical scores concerned mental health
issues
Students screened with
subclinical scores
School further
explores the needs of
School identifies
students (e.g. social,
students on SEN
learning, other
registry/record
mental health issues)

School seeks parent/legal guardian and

student’s consent to join SMHSS
Discuss with
school for the need
to bring up to join
SMHSS Students/Parents/
Legal guardians do
not give consent to
No Group/individual interview (簡介會)
Yes join SMHSS
with further assessment by ASWO*
(Appendix 14/15)

Follow operation Explore other suitable

workflow in Fig. III.1 resources to support the
and/or Fig. III.2 student
Continue…
 P a g e | 25

Figure IV.1 (Continued)

Continued from previous page

Other students with

suspected subclinical
anxiety and/or depressive
mood symptoms identified
through SMHSS after
Group/individual interview (簡介會) with
nurse’s standard brief
further assessment by ASWO*
assessment(Appendix 12)
(Appendix 14/15)

Students identified with Students screened with

other mental health subclinical anxiety and
problems depressive mood symptoms

Students require
Intervention by ASWO* (group/ individual)
further follow-up

Students’ problem
settled

Discuss with school for

the need to bring up to
join SMHSS as needed All cases reported to SMHSS case
(Fig. III.1) conference
Yes No

Follow operation Explore other suitable

workflow in Fig. III.1 resources to support the
and/or Fig. III.2 student Follow up as appropriate according to the
care plan
 P a g e | 26

5. Roles and Responsibilities

50. The Task Force, led by FHB, assumes an overall leading role to steer the planning, formulation and
implementation of the SMHSS. The involvement and division of responsibilities of various
stakeholders are as follows -

A. Medical
51. The designated psychiatric nurse, with support from multi-disciplinary healthcare team in HA, is
responsible for -
Roles
1. Steering the multi-disciplinary 
team via a school platform for
early identification of target 
students and determination of
suitable services and appropriate
level of support for referred cases
Responsibilities
Co-chairing the school-based multi-disciplinary
platform
Liaising with other multi-disciplinary team members to
identify target students for further support and
determine suitable services and appropriate level of
support for referred cases

2. Providing psychiatric input to  Conducting comprehensive psychiatric assessment,

target cases formulating care plan and providing suitable
psychiatric intervention for referred cases as
appropriate

3. Providing expert advice to other  Providing expert advice regarding psychiatric

multi-disciplinary members
4. Monitoring the implementation of 
psychiatric support for referred
cases, and referring them to other
suitable services as appropriate
5. Providing training to other 
stakeholders
perspective to other multi-disciplinary members to
facilitate students’ school adjustment
Working with other multi-disciplinary team members
via the school platform to review and adjust psychiatric
care plan as appropriate for referred cases
 Referring cases to appropriate services for continuity of
care
Providing relevant training to other multi-disciplinary
team members
 Providing training to other stakeholders such as school
personnel, parents, primary care service providers and
social workers to enhance their capacities in addressing
mental health issues of children and adolescents

52. The CP, with support from multi-disciplinary healthcare team in HA, is responsible for:
Roles
1. Providing mental health and 
psychological assessment,
consultation and psychological
intervention for referred cases
2. Monitoring the implementation of 
the care plan for respective
referred students from the clinical
psychology perspective
3. Overseeing the enhanced services 
delivered by the ASWO
4. Providing expert advice to other 
multi-disciplinary members
5. Providing training to other 
stakeholders
P a g e | 27
Responsibilities
Conducting assessment to identify psychological,
emotional and/or behavioral issues and providing
suitable consultation and intervention for cases referred
via the school platform in formulation and
implementation of the care and support
Attending the multi-disciplinary meetings and giving
advices on formulation of the care plan for the
respective students referred via the school platform
 Working with other multi-disciplinary team members
via the school platform to review and adjust the care
plan as appropriate for respective referred cases
Providing appropriate supervision to the ASWO and
supporting staff deployed from existing HA CAMHS to
deliver mental health promotion, early identification
and intervention services, including education talks,
training workshops, annual screening exercises and
individual/group interventions
Providing expert advice from the clinical psychology
perspective to other multi-disciplinary members to
facilitate students’ psychological functioning
Empowering other multi-disciplinary members to
support students with mental health needs via
consultation service
 Providing relevant training to other multi-disciplinary
team members
 P a g e | 28

53. The ASWO, with support from multi-disciplinary healthcare team in HA, is responsible for:
Roles Responsibilities
1. Providing the enhanced services to  Conducting the education talks, training workshops,
support the target students annual screening exercise
 Providing individual and/or group intervention to
students identified with sub-clinical anxiety and/or
depressive features in collaboration with the school
social worker and other multi-disciplinary team
members

2. Coordinating and working closely  Working closely with other multi-disciplinary team
with other professionals in the members to review and adjust the support services for
implementation of support cases under management
services for referred cases and  Making advice for cases under management on service
making advice on service matching and/or making suggestions to schools on
matching referrals to appropriate services as appropriate
 Escalating the cases under management to the clinical
psychologist as appropriate

3. Monitoring the implementation of  Attending the multi-disciplinary meetings for the

the care plan for students under
management
respective students under management as indicated
 Working with other multi-disciplinary team members
via the school platform to review and adjust the care
plan as appropriate for respective students under
management as indicated

4. Providing training to other  Providing training to other stakeholders such as school

stakeholders personnel, parents, primary care service providers and
social workers to enhance their capacities in addressing
mental health issues of children and adolescents in
school settings (e.g. teacher training workshops,
education talks)

B. Education
School personnel
54. The designated school coordinator is responsible for:
Roles
1. Coordinating the formulation and 
implementation logistics for the
communication platform in the school 
setting
 Liaising among different school personnel (e.g.
2. Participating in the comprehensive 
assessment if necessary via the multi-
disciplinary platform
 Collecting and compiling views from different
3. Formulating the care plan from 
educational perspective
4. Coordinating with relevant school 
personnel to work closely with the
multi-disciplinary team to implement
the care plan
5. Monitoring the implementation of the
care plan for respective students and
adjusting the plan to suit their needs if
necessary
P a g e | 29
Responsibilities
Co-chairing the school-based multi-disciplinary
platform
Attending multi-disciplinary meetings at least
twice a year
relevant class/subject teachers) to prepare relevant
documents and logistics for meetings
 Attending meetings with the Task Force on a need
basis
Coordinating data collection of students’
performance in school (e.g. academic results,
school attendance record, etc.)
stakeholders (e.g. parents, class/subject teachers)
Based on the care plan, work in collaboration with
relevant class/subject teachers and as appropriate,
school-based EP to devise the education plan (e.g.
prioritising learning goals and differentiating
learning materials for the student with reference to
his/her condition, etc.)
Liaising with relevant school personnel, including
class/subject teachers and student guidance
personnel to follow up the implementation of the
care plan in different school contexts
 Working with the school personnel to review and
adjust the implementation of accommodations if
needed
 Working with the school personnel to review and
adjust the implementation of support measures if
needed
 Completing evaluation form/ questionnaire
 P a g e | 30

55. The designated school-based EP is responsible for:

Roles Responsibilities
1. Providing support in the comprehensive  Conducting psycho-educational assessment with
assessment via the multi-disciplinary students on need basis to obtain information on
platform students’ functioning (e.g. on learning needs and
school adjustment, etc.)
 Communicating with parents and teachers to
obtain students’ performance in different contexts
related to their educational performance
 Working in collaboration with other multi-
disciplinary team members on understanding the
needs of the target students

2. Providing consultation in formulating  Providing consultation to the school personnel in

the care plan from educational formulation and implementation of the educational
psychology perspective plan for the students
 Working in collaboration with other multi-
disciplinary team members in devising
intervention and support strategies for the target
students

3. Providing professional support to the  Providing relevant training to other multi-

multi-disciplinary team disciplinary team members

C. Social

56. The designated school social worker is responsible for:

Roles Responsibilities
1. Participating in the comprehensive  Facilitating assessment and communicating
assessment via the multi-disciplinary with the parents and the students to obtain
platform family background and the students’ social and
emotional conditions
 Attending multi-disciplinary meetings to share
professional knowledge, significant information
and concern on the parents and the students on a
need-to-know basis
 Giving views on the formulation of social care
plan for the students and their families
 P a g e | 31

Roles Responsibilities
2. Formulating care plan from social care  Preparing the students and the parents for the
perspective tasks involved in the intervention process so as
to enlist their cooperation
 Taking an inclusive and systematic perspective
to devise the social care plan to help the students
solve their social and emotional problems

3. Providing family support relating to  Providing support to the family in aspects such
social care aspect and considering their as parenting skills, parent-child activities, etc. to
long-term welfare and post-recovery facilitate the implementation of the care plan of
needs to be involved in the care plan the student
 Communicating and liaising with other
professionals to support the implementation of
social care plan of the student and arrange for
the provision of appropriate services
 Linking up community-based social services for
the family (Appendix 3)

4. Monitoring the implementation of the  Reviewing the progress of the implementation

care plan in social care aspect for
respective students, and adjusting the
plan to suit their needs
 Maintaining communication with other multi-
5. Coordinating and working closely with 
other professionals to identify the high-
risk families and their children’s needs
for social care services in the
community
6. Providing expert advice to other multi- 
disciplinary members
of the care plan regularly and adjusting the
social care plan with participation of the
students and their families as appropriate to suit
their needs.
disciplinary team members about the case
progress to facilitate smooth collaboration in
service delivery
Communicating and liaising with other
professionals working with the family to
identify if there is any other family member(s)
who may need social care services and arrange
for appropriate service provision (Appendix 3)
Providing expert advice regarding social care
perspective to other multi-disciplinary members
to facilitate students’ social functioning
 P a g e | 32

6. Documentation

57. All documents compiled in the SMHSS, including the parent/legal guardian consent form (including
updated consent form of version 1.0(2018/19)_20180901), assessment forms, integrated
assessment and care plan etc., should be placed into individual student folder in a designated area
(e.g. a cabinet with lock) in school office. Only designated personnel involved in the SMHSS would
have access to the designated area.

58. The individual student folder should be kept at school until the student left the school or his/her
parents/legal guardians withdrew their consent for the student to participate in the SMHSS.

59. The school should have well-established mechanism and guidelines for storing, retrieving and
handling of the restricted documents/personal data, including the consent form, assessment
information, Integrated Assessment and Care Plan, records of support measures and interventions
provided to the students, etc.
 P a g e | 33

60. A summary of documents for students participating in the SMHSS is as follows:

Students Students Students identified
known to not known with subclinical anxiety
HA C&A to HA C&A and/or depressive
psychiatric psychiatric mood symptoms
services services
Student Mental Health Support Scheme -   
Parent/Legal Guardian Consent Form
(Version 1.0) (2018/19)_20180901 (Appendix 4)
Assessment form – HA designated 
psychiatric nurse (Appendix 5)
Assessment form – School personnel (Appendix   As needed, subject to a joint
6) decision with relevant school
Assessment form -- School Social Work   personnel and/or school social
Service (Appendix 7) worker
Integrated Assessment and Care Plan (For 
Students known to HA C&A Psychiatric
Services) (Appendix 8)
Integrated Assessment and Care Plan (For  As needed if the student
Students not known to HA C&A Psychiatric requires further follow-up
Services) (Appendix 9) after the intervention by
ASWO and a joint decision
with relevant school personnel
and/or school social worker to
bring up the student to the
SMHSS
Standard brief assessment – HA designated 
psychiatric nurse
(for cases not known to HA C&A psychiatric
services) (Appendix 12)
Assessment form – HA assistant social work 
officer (Group Interview) (Appendix 14)
– OR –
Assessment form – HA assistant social work
officer (Individual Interview) (Appendix 15)
 P a g e | 34

7. Staff Training

61. The training are categorised by two levels designated for two groups of participants, including
designated professional staff as well as school personnel and supporting staff.

Training for the designated professional staff

(Designated psychiatric nurses, CPs, ASWOs, Designated school coordinators, school social workers, nurses, EPs,
nominated social workers from IFSCs/ISCs /MSSUs/FCPSUs/ICCMWs, etc.)

62. The main focus of the training course for designated professional staff is on

(a) Foundation training on diagnosis and management of students’ mental health problems
(b) Case plan formulation and preparation for school-based multi-disciplinary case conference and
platform
(c) Maintenance of teachers’ mental well-being and healthy lifestyle
(d) Overview of mental health support services for students and introduction of evidence-based
services
(e) Skill-based and practical training for management and handling of students with mental health
problems at school level
(f) Practical skills to communicate with parents of student with mental health needs
(g) Case studies, demonstration and discussion of commonly encountered problems/difficulties in
school setting

63. Seven identical batches of training course (with 31 training hours per batch) were arranged for
designated professional staff. The training areas include the following:

Areas to be covered

Training topics include mental health problems of students with:

 Oppositional Defiant Disorder

 Conduct Disorder
 Depression
 Anxiety Disorder
 Obsessive Compulsive Disorder
 Early Psychosis
 Bipolar Affective Disorder
 Substance Abuse
 Eating Disorders
 Substance Abuse
 P a g e | 35

Areas to be covered

 Tics / Tourette Syndrome

 Mental health problems comorbid with Attention Deficit / Hyperactivity Disorder (AD/HD)
and/or Autism Spectrum Disorder (ASD)
Foundation training on diagnosis and management student mental health problems

Care plan formulation & preparation for school based multidisciplinary case conference/platform

Skill-based and practical training for management and handling of students with mental health
problems at school level

Practical skills to communicate with parents of students with mental health needs

Case studies, demonstration and discussion of commonly encountered problems/difficulties in

school setting

Maintenance of teachers’ own mental well-being and healthy lifestyle

Overview of mental health support for children and adolescents

Evidence-based treatment programmes available at school which support students with specific
mental health problems

Clinical attachment at respective cluster-based HA Child & Adolescent Psychiatric Centre

Training for the school personnel and supporting staff:

64. The main focus of the training course for general school personnel is on

(a) Needs of children and adolescents with mental health problems

(b) Basic concepts and understanding of students with different mental health problems
(c) Maintenance of teachers’ mental well-being and healthy lifestyle
(d) Overview of mental health support services for students and introduction of evidence-based
services
(e) Skill-based and practical training for management and handling of students with mental health
problems at school level
(f) Practical skills to communicate with parents of student with mental health needs
(g) Case studies, demonstration and discussion of commonly encountered problems/difficulties
in school setting
 P a g e | 36

65. Three identical batches of training course (with 15 training hours per batch) are arranged for school
personnel and supporting staff. The training areas include the following:

Areas to be covered

Training topics include mental health problems of students with:

 Depression
 Anxiety Disorder
 Obsessive Compulsive Disorder
 Early Psychosis
 Bipolar Affective Disorder
 Mental health problems comorbid with Attention Deficit / Hyperactivity Disorder (AD/HD)
and/or Autism Spectrum Disorder (ASD)

Needs of children and adolescents with mental health problems and basic concepts and
understanding of student mental health problems

Skill-based and practical training for management and handling of students with mental health
problems at school level

Practical skills to communicate with parents of students with mental health needs

Case demonstration and discussion

Overview of mental health support for children and adolescents

Maintenance of teachers’ own mental well-being and healthy lifestyle

Evidence-based treatment programmes available at school which support students with specific
mental health problems
 P a g e | 37

8. Evaluation
66. The SMHSS will be enhanced with new service elements which are expected to further enhance the
identification and support services for students with mental health needs. FHB has commissioned
the Department of Psychiatry, the Chinese University of Hong Kong to conduct an evaluation for
the enhanced SMHSS. Based on the findings of the evaluation, FHB will consider the way forward
of student mental health support services.

67. The evaluation will mainly evaluate the effectiveness of the enhanced service model; the
effectiveness of identification of and support to HA’s unknown cases; and resource implication, with
a view to making recommendations on the way forward of the school-based support services.
 P a g e | 38

IV. Abbreviations
AD/HD or ADHD Attention Deficit / Hyperactivity Disorder

ASD Autism Spectrum Disorder

C&A Child and Adolescent

CD Conduct Disorder

EASY Early Assessment Service for Young People with Psychosis

EDB Education Bureau

EP Educational Psychologist

FCPSU Family and Child Protective Services Unit

FHB Food and Health Bureau

GAD-7 Generalised Anxiety Disorder 7-item scale

HA Hospital Authority

ICYSC Integrated Children and Youth Services Centre

IFSC Integrated Family Service Centre

ISC Integrated Services Centre

KWC Kowloon West Cluster

MDT Multi-disciplinary team

MSSU Medical Social Services Unit

MSW Medical Social Worker

NGO Non-governmental Organisation

ODD Oppositional Defiant Disorder

OCD Obsessive-compulsive Disorder

PHQ-9 Patient Health Questionnaire-9

SEN Special Educational Needs

SWD Social Welfare Department

WHO World Heatlh Organization

 P a g e | 39

V. Appendices

Appendix 1: Definition of the Three-Tier Service Delivery Model

Tier 1–Universal Prevention, Early Detection, Intervention and Mental Health Maintenance

Tier-1 services refer to prevention, early intervention and mental health maintenance strategies that
aim to prevent behavioural and emotional problems from developing in children and adolescents. They
include public education and health promotion efforts to build awareness, resilience and healthy lifestyles,
general health and mental health maintenance, parenting programmes and screening services to aid early
identification of problems, handling of mild mental health issues, and referral of the more complicated cases
to specialist services. Above all is to build a caring and enabling family, school and social environment
for the growth and development of children. Advice, counselling and support are provided to parents by
social workers, school teachers, primary care doctors, paediatricians, etc. These professionals are not
necessarily trained as specialists in mental health. But they will be supported by specialists through
training and supervision so that they are equipped with the necessary skills and knowledge in provision of
Tier-1 services to children. Given their close and frequent contacts with the child concerned, it is
important that they should be able to formulate care plan and provide appropriate interventions and support
for the children and their family. For children and adolescents with relatively complex mental health
problems, further support from Tier 2 (e.g. provision of a more elaborated care plan, as well as more
structured and targeted intervention) will be solicited.

Tier 2–Targeted Intervention and Important Linkage between Tier 1 and Tier 3

Tier 2 should serve as a bridge between Tier 1 and Tier 3 to (i) provide more structured and targeted
assessment and intervention for relatively complex cases identified by Tier 1, (ii) provide ongoing
management and support for children who are attending Tier-3 services and work closely with Tier 3 to
ensure smooth transition of care and support services for children with moderate to severe mental health
problems.

One of the functions of Tier 2 is to provide more structured assessment for children and young people
whose behaviours and/or emotional difficulties are progressively affecting their psychological, social and
educational function, and have placed them at risk of developing more complex mental health problems.
The aim is to minimise negative impacts and prevent escalation to more serious problems. After
assessment, more elaborated care plan, as well as targeted and structured intervention, should be formulated.
Towards this end, professionals at Tier 2 should work closely with those at Tier 1 to equip them with
appropriate training and support to develop the skills in delivering interventions and provide appropriate
care in the community for those with mental health problems. Intervention at Tier 2 will include medical
 P a g e | 40

treatment, social care (such as rehabilitation services and other services to look after the general welfare of
the child and the family) and education support. An evidence-based model is the establishment of a
school-based multi-disciplinary platform through which a multi-disciplinary team comprising parents,
teachers, educational psychologists, school social workers and healthcare professionals should be formed
to review the progress of each case and adjust the intervention strategies or care plans where necessary. The
advantage of the model is to keep treatment and support in the community, reduce disruptions caused to the
children and their families by having to attend specialist services, and to help the children to maintain their
conditions in familiar environment. Early intervention can also reduce the need for referral to specialist
services.

Secondly, the multi-disciplinary team should work closely with Tier 3 to implement, adjust and
monitor the overall care plan and progress of children who are known to Tier 3 with a view to achieving
better psychological, social and school adjustment. In case of deterioration in children’s functioning or
mental state, Tier-2 professionals could consider if escalation to Tier 3 is required. Vice versa, if children’s
conditions are stabilised with progress, their cases can be downloaded to Tier 2 to optimise the use of
resources in both tiers. Whereas the focus of Tier-1 intervention is on prevention, early detection, timely
intervention and mental health maintenance, Tier 2 is the key to ensure that the child will stay in productive
education, continue to grow and develop like their peers in families and community, while having their
mental health issues and learning disabilities attended to and addressed.

Tier 3–Specialist Intervention

Specialist intervention is provided to children and adolescents who are experiencing moderate to
severe mental health and emotional difficulties which are having a significant impact on daily psychological,
social, and educational functioning. They also provide crisis resolution, in-patient and day care services,
and residential care to children and adolescents at immediate risk or with very complex or enduring
problems who need intensive therapeutic care at the tertiary level. Specific long-term care plan will be
formulated by respective healthcare, social and/or education professionals, with intensive and targeted care
being provided to meet the complex needs of patients. This tier will work closely with Tier 2 to ensure
continuity in care being provided to children and adolescents in need. Partnership between health,
education and social services is essential, as disorders of a more complex/serious nature require even more
intensive intervention by specialists of the respective field. Medical intervention apart, rehabilitation and
long-term care services in the community as well as continuous learning support from schools and
employment support from social agencies are equally important to facilitate the child’s recovery and re-
integration in society.
 P a g e | 41

Appendix 2: Stepped Care Model - Multi-sectoral Participation

Tier Sector Personnel Roles and functions

Tier 1 Health  GPs Healthcare professionals in the primary care settings (e.g. outpatient
 Paediatricians clinics, family clinics, MCHCs, etc.) are usually the first point of contact
 Family doctors when a child needs health advice. Primary health care professionals
 Nurses will help identify early behavioural and emotional problems in children
and adolescents, through health maintenance programmes (e.g.
developmental surveillance scheme conducted in partnership with
parents at MCHCs, etc.) or clinic encounters for other health issues,
provide early intervention (e.g. Positive Parenting Programme (Triple-P)
and refer them for secondary services when necessary.

Social  Social workers Integrated Children and Youth Services Centres (ICYSCs) provide a wide
range of developmental and support services at neighbourhood level to
meet the multifarious need of children and youth aged from 6 to 24.
This will contribute to the positive development of their mental health.
Social workers can help identify those who may have emotional
problems and behavioural problems with regard to distress. Young
people with less serious problems and distress will be able to draw on
support from social workers and peers to relieve their problems such
that the conditions will remit without a need for referral to services at
the higher levels. More complicated cases may be referred to second
tier when needed.

IFSCs and ISCs operated by SWD and NGOs over the territory provide a
spectrum of preventive, supportive and remedial welfare services to
individuals and families in need, including the children and adolescents
with mental health problems and their families. Social workers will
thoroughly assess the welfare needs of the individuals and families and
provide / refer them for appropriate services.
 P a g e | 42

Tier Sector Personnel Roles and functions

Social  Social workers Early identification and intervention can effectively prevent family
(Cont’d) problems from deteriorating. As some families in need are reluctant to
seek help, IFSCs and ISCs, FCPSUs and Psychiatric MSSUs have
implemented the Family Support Programme. Through telephone
calls, home visits and other outreaching services, social workers contact
the families with members at risk of domestic violence or mental illness
and those with problems of social isolation and refer them to a host of
support services. The service units will also recruit and train volunteers,
including those with personal experience in overcoming family
problems or crises, so that they can contact these families and
encourage them to receive appropriate support services with a view to
preventing the problems from deteriorating.

School social work service is operated by non-governmental

organisations (NGOs). School social workers are an integral link
between school, home, and community in helping students achieve
their full potential. They work closely with school personnel as well as
students and families, providing advice in school discipline policies,
mental health intervention, crisis management, and support services.

Education  Teachers School-wide promotion on mental health will enhance students’

 Student awareness on mental health. Schools also provide an important
guidance platform for students to learn problem solving and coping skills.
personnel School personnel, including teachers, student guidance personnel and
 Educational educational psychologist will collaborate with professionals in other
psychologists sectors to help students enhance social/emotional or behavioural
adjustment and well-being and will identify those with early signs of
mental health difficulties and refer cases to the second tier when
needed. This will help reduce the consequences of early mental
health difficulties that lead to adverse outcomes. For pre-primary
children, teachers will promote parenting, identify and refer children in
need for assessment and support services.
 P a g e | 43

Tier Sector Personnel Roles and functions

Tier 2 Health  GPs Both primary and secondary healthcare services will be provided to
 Paediatricians the child/adolescent in need, depending on the nature of support
 Family doctors required. At the primary care setting (e.g. outpatient clinics, family
clinics, etc.) healthcare professionals with specialised training in
 Psychiatric Nurses
mental health will provide consultation to cases referred from Tier 1.
 Occupational
If a second opinion is needed, experienced healthcare professionals
therapists
or specialists will be brought into play to provide further advice to the
 Speech therapists cases concerned. Training to primary healthcare professionals to
 Clinical enhance their capacities in diagnosis and treatment of mental
psychologists disorders in children and adolescents would be provided by mental
 Child psychiatrists health specialists. Major functions of the health sector are
summarised below -
 Conduct structured assessment and triage;
 Work closely with the Team of Tier 2 to formulate comprehensive
clinical care plan for individual patient;
 Provide expert advice regarding medical support for cases
concerned;
 Monitor the implementation of the care plan in mental health
aspect for respective school-aged children/ adolescents, and refer
school-aged children/ adolescents to Tier 1 for mental health
maintenance or Tier 3 for intensive medical care if necessary; and
 Provide training to primary healthcare and other relevant
professionals to enhance their capacities in addressing mental
health issues of children and adolescents.

Social  Social workers Apart from treatment of mental problems, psychosocial intervention
and users’ participation are a major part of the care plan. Social
workers in schools and community-based service work closely
together with health and education professionals at Tier 2 to
formulate a comprehensive care plan for the child concerned. Major
functions of the social sector are summarised below -
 Work closely with the Team at Tier 2 to provide expert advice
regarding social support for cases concerned and formulate a
comprehensive care plan on social care perspective for the child
concerned;
 Provide expert advice regarding social care support for cases
concerned;
 Monitor the implementation of the care plan in social care aspect
for the child and his/her family and adjust the plan to suit their
needs;
 P a g e | 44

Tier Sector Personnel Roles and functions

Social  Social workers  Provide family support relating to social care aspect and
(Cont’d) consider their long-term welfare and post-recovery needs to be
involved in the care plan;
 Monitor the implementation of the care plan in social care
aspect for respective school-aged children/ adolescents, and
adjust the plan to suit their needs; and
 Coordinate and work closely with the social workers in the
community (e.g. IFSCs, ISCs, ICYSCs, ICCMW, etc.) to identify the
high risk families and their children’s needs on community social
welfare and suitable NGO services.

Education  Teachers Children and adolescents with mental health problems may need
 Student guidance additional support from schools, as they may find it difficult to cope
personnel with academic and social demands during their pathway of recovery.
 Educational Teachers, student guidance personnel, school social workers and
psychologists educational psychologists will work closely with professionals in other
sectors to attend to their problems and needs. Early intervention of
mental health problems (e.g. counselling, continuity of support in a
caring and familiar environment, etc.) has long-term benefits in
turning students away from a path leading to issues such as substance
misuse/dependence, isolation, self-neglect. Major functions of the
education sector are summarised below -
 Coordinate the formulation and implementation logistics for
the communication platform in the school setting involving
cases, parents/legal guardians and all relevant care
professionals (i.e. teachers, school social workers, educational
psychologists, healthcare professionals)
 Work closely with the Team at Tier 2 to formulate a
comprehensive care plan on educational perspective for the
child concerned
 Work closely with the Team at Tier 2 to implement the care
plan in order to provide help to students to enhance social,
emotional or behavioural adjustment, educational adjustment
and overall well-being.
 Monitor the implementation of the care plan in education
aspect for respective students, and adjust the plan to suit their
needs if necessary.
 P a g e | 45

Tier Sector Personnel Roles and functions

Tier 3 Health  Child psychiatrists Secondary and tertiary services are provided to children/adolescents
 Psychiatric nurses with moderate to severe mental disorders, including eating disorders,
 Occupational addictions, schizophrenia, etc. These services include crisis
therapists resolution, in-patient and day care services. Multi-disciplinary
 Speech therapists professionals including child psychiatrists, clinical psychologists,
 Clinical speech therapists, psychiatric nurses, occupational therapist, etc., will
psychologists work together to provide treatment in the acute phase and draw up a
longer-term care plan (involving professionals from the education and
social sectors as well). These children and adolescents may need
longer-term therapeutic work that deals with more complex
developmental issues, and deeper-seated and long-standing
emotional, psychological and mental problems.

Social  Social workers Once a child/adolescent is discharged from hospital, the long-term
care of the child/adolescent has to be taken care of by a team of
personnel from the health, education and social sectors. Social
workers will liaise with the hospital, the school, and the family to
ensure a continuity of care is provided to the child.

Education  Teachers Personnel from the education sector should establish proper and
 Student guidance close links with social welfare, medical and psychiatric services for
personnel consultation and referral. Teachers, student guidance personnel,
 Educational and educational psychologists will collaborate with professionals in
psychologists other sectors to help students with mental disorders re-enter school
and adapt to school life, in tandem with the medical treatment and
rehabilitation requirements. Counselling services and additional
resources provided by schools can complement the medical
treatment.
 P a g e | 46

Appendix 3: Relevant social and family support services for children and
adolescents with mental health needs in the SMHSS

Medical Social Services – Medical Social Services Unit (MSSU)

Social Welfare Department (SWD) has stationed medical social workers (MSWs) in psychiatric
hospitals and clinics of HA to provide medical social services to persons with mental health problems,
including children and adolescents. MSWs provide timely psychosocial intervention to the service users
and help them cope with or solve problems arising from their illness. MSWs are also members of the
EASY programme to offer one-stop support services to facilitate early detection and early intervention
of mental health problems of young people.

Integrated Family Service

IFSCs and ISCs provide a spectrum of preventive, supportive and remedial services to address the
multifarious needs of individuals and families of specific localities. The IFSC/ISC services include
enquiry service, resource corner, family life education, parent-child activities, group work service,
programme activities, volunteer training and service, outreaching service, counselling service and
referral service, etc. for individuals and families in need. IFSCs/ISCs have close collaboration with
MCHCs of DH, HA, pre-primary institutions, etc. to identify at-risk pregnant women, mothers with
postnatal depression (PND), as well as children and families in need (for example, those with
psychosocial needs, pre-primary children with health, developmental and behavioural problems, etc.).
Children and families in need are referred to appropriate service units for follow-up.

Students with family issues can be referred to the relevant IFSCs, ISCs, FCPSUs, MSSUs or other
relevant social service units for follow-up in accordance with their respective service ambits via the school
social workers. The designated school social workers would help coordinate and link up the community
social services for the students and their families. Social workers from IFSCs, ISCs, FCPSUs and MSSUs
will be invited to join the case conferences of the school-based multi-disciplinary platform for cases known
to them if appropriate.
 P a g e | 47

Appendix 4: Student Mental Health Support Scheme - Parent/Legal Guardian

Consent Form
(Version 1.0) (2018/19)_20180901

醫教社同心協作計劃
Student Mental Health Support Scheme

「醫教社同心協作計劃」簡介

食物及衞生局聯同醫院管理局、教育局和社會福利署由2016/17學年起，推出「醫教社同心協

作計劃」(「計劃」)，在每間參與「計劃」的學校內建立跨專業協作平台，為有精神健康需要

的學生提供適切的支援服務。

Introduction of the Student Mental Health Support Scheme

The Food and Health Bureau, in collaboration with the Hospital Authority, the Education Bureau and

the Social Welfare Department, has launched the “Student Mental Health Support Scheme”

(“SMHSS”) since the 2016/17 school year. A multi-disciplinary collaborative platform is set up in

each participating school to provide appropriate support services for students with mental health

needs.
 P a g e | 48

家長/法定監護人同意書
Parent/Legal Guardian Consent Form
本人之個人資料如下：
My personal particulars are as follows:-

姓名： 身分證號碼： 聯絡電話：

Name：_____________H.K. Identity Card No.：______________ ( ) Contact Phone No.：_____________
地址：
Address：
______________________________________________________________________________________

本人同意
I give consent for
本人子女/受監護者* 出生日期：
my child/ward *____________________________ Date of Birth: _____________________
身分證號碼/學生編號(STRN)：
H. K. Identity Card No./ Student Reference No.(STRN): ___________________________________ ( )
接受「醫教社同心協作計劃」(下稱「計劃」)提供之服務。
to receive the services provided by the Student Mental Health Support Scheme (“SMHSS”).

本人明白及同意在「計劃」下，以下政府決策局/部門/學校/機構(「有關機構」)可按需要索取及交流有關
本人及上述學生的個人資料(「相關個人資料」)，以作為治療及復康、「計劃」的成效評估，以及和「計
劃」相關的培訓之用，並按需要為上述學生提供合適的醫療/教育支援/福利服務。此外，相關個人資料或
會用以整體策劃學生精神健康支援服務。
I understand and agree to accept that the following government bureaux/departments/school/organisations (“the Relevant
Organisations”) will collect and exchange my personal data and the above student’s personal data (“the Related Personal
Data”) on a need-to-know basis for the purpose of treatment and rehabilitation, evaluation of SMHSS, provision of training
relating to SMHSS, as well as for the provision of appropriate medical/educational support/welfare services on a need basis
under SMHSS. In addition, the Related Personal Data may be used for the overall planning of the student mental health
support services.
1) [學校名稱 School Name]^
2) 食物及衞生局 (Food and Health Bureau)
3) 醫院管理局，包括精神科服務單位 (Hospital Authority, including Psychiatric Service Units)
4) 教育局 (Education Bureau)
5) 社 會 福 利 署 [ 服 務 單 位 名 稱 ]( 如 適 用 )(Social Welfare Department [Name of Service Unit](if applicable)^
_
6) [校本教育心理學家所屬機構/服務單位名稱](如適用)_([Name of Organisation/Service Unit providing school-based
educational psychology service (if applicable))^
7) [學校社工所屬機構/服務單位名稱] (如適用) ([Name of Organisation/Service Unit providing school social work
service] (if applicable))^
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8) 其他非政府機構/服務單位 ， 包括綜合家庭服務中心 、 綜合服務中心等(如適用) [Other Non-governmental

Organisation(s)/Service Unit(s), including Integrated Family Service Centre, Integrated Services Centre, etc.] (if
applicable))^

9) 「計劃」之成效評估機構 (The commissioned institution for the purpose of evaluation of the SMHSS)
10) 「計劃」之培訓機構 (The commissioned institute which provides training services to relevant professionals under
the SMHSS)

本人明白本人有權在任何時間以書面通知方式撤回本人的同意並停止上述學生參與「計劃」及有關機構
就「計劃」繼續使用相關個人資料。
I understand that I have the right, at any time, to withdraw my consent by written notice to cease the above student
from participating in SMHSS and the Relevant Organisations to further use of the Related Personal Data.

本人已通知上述學生就此同意書內所述的目的(包括作為「計劃」的成效評估之用)索取及交流其個人資料
事宜。上述學生明白和同意並在下方簽署。
I have notified the above student about the collection and exchange of his/her personal data mentioned in this
Consent Form for the purposes (including for the evaluation of SMHSS) stated in this Consent Form. The above
student understands and agrees, and signs below.

簽署：
Signature：____________________________________
(學生 – Student)
簽署：
Signature：____________________________________
(家長/法定監護人 – Parent/Legal Guardian)
日期：
Date：________________________________________

* 請刪去不適用者
* Please delete whichever is not applicable
^ 請填上適當名稱
^ Please fill in the name as appropriate
正本： 學校存檔
Original : School
副本送： 家長/法定監護人
Copy : Parent / Legal Guardian
Consent form version 1.0(2018/19)_20180901
 P a g e | 50

Appendix 5: Assessment form – HA designated psychiatric nurse

Name: ___________________( ) Sex/Age: ______
Student Mental Health DOB: ________ Clinical Register No: ________________________
HKID: _______________
Support Scheme
 KEC – UCH  KWC – YMTCPC / KCCAPC
Clinical Assessment Form  HKW – QMH  NTE – AHNH  NTW – CPH

Date of Assessment: _____________________________ Case Medical Officer:

Diagnosis: __________________________________

1. Physical State / Condition

Physique:  Obesity  Over-weighted  Average  Under-weighted
Eat:  No Problem  Change in Appetite  Food Fad  Others
(Please specify: ______________________________________________________________________________)
Elimination:  Normal  Diarrhoea  Constipated  Incontinence (Urinary/Faecal/Double)
(Please specify: ______________________________________________________________________________)
Use of illicit drugs:  Denied  Once  Regular (Please specify: _____________________________)
History of Allergy:  No / Unknown  Medication  Food  Others
(Please specify: ______________________________________________________________________________)
Physical illness / Disability / Problem: __________________________________________________________

2. Level of Functioning
Perception of Self:  Self-confident  Satisfied with Self  Lack of confidence  Worthlessness  Others
(Please specify: )
Strengths / Hobby:
Perception of Future:  Hopeful  Well-planned  No Planning  Hopeless  Others
(Please specify: ______________________________________________________________________________)
Hopes and Dreams: _________________________________________________________________________
Way of Coping:  Avoidance  Avolitional  Blaming others  Self-blamed  Self-harmed
 Problem-focused  Seeking Support  Others (Please specify: _________________________________)
Activities of Daily Living:  Independent  Prompting  Supervised  Dependent
(Please specify: ______________________________________________________________________________)
Academic Performance:  Good  Above Average  Average  Below Average  Poor  N/A
Attendance to School:  Regular  Irregular  Refuse to attend  N/A
(Please specify: ______________________________________________________________________________)
Organisation Skill:  Good  Average  Fair  Poor
(Please specify: ______________________________________________________________________________)
Leisure Activities:  Active  Passive  N/A
(Please specify: ______________________________________________________________________________)
Time Management:  Well-planned  Fair  Dependent  No Planning  Poor
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3. Inter-personal / Social Relationship

Relationship with: - *Father/Carer ( )  Good  Satisfactory  Fair  Poor  N/A

(* Delete as appropriate) - *Mother/Carer ( )  Good  Satisfactory  Fair  Poor  N/A

Relationship with: - Siblings ( )  Good  Satisfactory  Fair  Poor  N/A

(Please specify: ______________________________________________________________________________)

Relationship with Schoolmates  Good  Satisfactory  Fair  Poor  N/A

(Please specify: ______________________________________________________________________________)

Relationship with Peers  Good  Satisfactory  Fair  Poor  N/A

(Please specify: ______________________________________________________________________________)

Relationship with Teachers  Good  Satisfactory  Fair  Poor  N/A

(Please specify: ______________________________________________________________________________)

4. Social Skills
Eye-contact:  Sustain  Brief  Fleeting  Poor  Avoid

- Interaction:  Over-passionate  Friendly  Active  Co-operative  Passive

 Avoid  Withdraw  Aloof

- Verbal Expression:  Spontaneous  Lack of reciprocal  Weak  Mute (Please

specify: ______________________________________________________________________________)

Perspective Taking Ability:  Good  Fair  Weak (Please

specify: ______________________________________________________________________________)

5. Mental State
5.1 General Condition:

Grooming:  Well-groomed  Unkempt  Exaggerated  Others

(Please specify: ______________________________________________________________________________)

Personal Hygiene:  Satisfactory  Unsatisfactory  Others (Please specify: )

Consciousness:  Conscious  Confused  Dull  Others

(Please specify: ______________________________________________________________________________)

Overall Contact:  Spontaneous  Passive  Withdraw  Others

(Please specify: )

Attitude:  Co-operative  Shy  Submissive  Childish  Playful  Carefree 

Uncooperative  Hesitated  Evasive  Suspicious  Challenging  Hostile  Others
(Please specify: ______________________________________________________________________________)
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Mood:  Neutral  Anxious  Depressive  Elated  Irritable  Others

(Please specify: ______________________________________________________________________________)

Affect:  Congruent  Incongruent  Blunt  Labile  Exaggerated  Others

(Please specify: )

Speech:  Coherent  Relevant  Incoherent  Irrelevant  Slurred  Talkative 

Superficial  Mute  Others (Please specify: )

Attentiveness:  Attentive  Inattentive  Distractible  Disinterested  Pre-occupied

 Attention Span:

5.2 Mental Condition:

Hallucination:  Denied  Auditory  Visual  Olfactory  Tactile  Gustatory (Please

specify: )

Delusion:  Denied  Persecution  Reference  Hypochondriasis  Guilt  Control 

Grandiosity  Love (Please specify: )

Thought Alienation:  Denied  Thought Insertion  Thought Withdrawal  Thought Broadcasting

(Please specify: )

Formal Thought  N.A.D  Echolalia  Thought Blocking  Circumstantiality  Flight of Idea

Disorder:  Pressure of Speech  Loosening of Association  Others

(Please specify: )

Emotional Control:  Good  Fair  Poor  Impulsive

(Please specify: )

Insight:  Intact  Partial  No

Behaviour:  Appropriate  Aggressive  Bizarre  Compulsive  Disturbing

 Hyperactive  Mannerism  Non-compliance  Oppositional  Restless  Rigid 
Retarded  Self-giggling  Self-muttering  Avoid fear provocative  Others

(Please specify: )

5.3 Risk Level:

Suicidal Idea:  Denied  Fleeting  Vague  Concrete

Warning Signs of Suicidal Intent:  N.A.D.  Suicidal Notes  Deliberate Self-harm

(Please specify: )

Suicide Plan:  Denied  Jump from height  Wrist-cutting  Charcoal-burning  Hanging

 Drug Overdose  Others (Please specify: )

Suicidal Attempt:  No  Yes (Please specify: )

 P a g e | 53

Aggression:  No  Verbal  Physical (Please specify: )

5.4 Medication Taking:

Current Medications: as at (Date)

Drug Compliance:  Compliant  Self-adjusting  Doubtful  Non-compliant

 Supervised by

Side Effect:  Denied  EPS  Constipation  Amenorrhoea  Tiredness  Dizziness 

Poor appetite  Weight Gain  Dry Mouth  Others (Please specify: )

6. Carer’s Stress In this section, please specify the respondent by writing “Mo” for Mother, “Fa” for Father and “MC” for Main Carer.

- Carer ( ) Stress level: ___ / 10 (0 is nil and 10 is the highest degree of stress)

Reasons:  Unable to manage patient's problem  No psychological support  Financial problem

 Worry about the future of patient  Others (Please specify: )

Social Support Networks:  Friends  Relatives  Social Worker

 Church  Other  Nil

Marital Relationship:  Good  Satisfactory  Fair  Poor (Please specify: )

Carer’s Emotion:  Calm  Anxious  Irritable  Agitated  Fluctuated  Others

(Please specify: )

Parents’ Attitude:  Supportive  Caring  Over-protective  Conditional Love  Demanding

 Judgmental  Punishment  Distant  Ignorance  Rejecting  Other
(Please specify: )

Parenting Style:  Authoritative  Authoritarian  Indulgent  Neglectful

(Please specify: )

Parent’s understanding of patient’s Illness:  Fully  Partial  Not understand

Parent’s academic expectation:  Unrealistic  High  Appropriate  Low  No

Parent’s acceptance of patient’s problems:  Accept  Partial  Not Accept

Consistency and Effectiveness of Parenting:  Consistent  Inconsistent  Effective  Ineffective

Parent’s main concerns:

Time spent on completing this assessment:

Assessment done by: Name:

( Signature )
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Appendix 6: Assessment form – School personnel

「醫教社同心協作計劃」-《學生需要評估表》

_____/_____學年
第一部分：學生背景資料
學生就讀的學校：____________________  小學 /  中學 班別：________
學生姓名：___________________ 出生日期：_______________ 性別：__________
填表人姓名：_________________ 填表人職位：*輔導主任/特殊教育統籌主任/其他，請註明：________________
填表日期： _______年______月______日

(甲) 精神健康情況/特殊教育需要
1. 學生是否有接受兒童及青少年精神健康服務?
 是 (請繼續回答(a) 至 (c))  否  正輪候有關服務 (輪候中的機構：
_______________)
(a) 確診的精神病患類別 (如適用)：  思覺失調 抑鬱症 躁鬱症 焦慮症 強迫症
其他：__________________
(b) 確診的機構/人員：_________________________________________________________________
(c) 確診的日期(如適用)： ___________年_______月_______日
(d) 如學生未有確診的精神病患，請註明學生 在精神健康方面需要關注的地方及懷疑的精神病患類別：
____________________________________________________________________________________________________

2. 學生是否有其他已確診的特殊教育需要?  是 (請繼續回答(a) 至 (c))  否

# #
(a) 特殊教育需要類別：  讀寫困難 智力障礙(*輕度/中度/嚴重) 自閉症譜系 注意力不足/過度活躍症
肢體傷殘 視覺障礙 聽覺障礙 語言障礙
(b) 確診機構/人員: ________________________________________________________________________________

#
(c) 如學生患有自閉症譜系或注意力不足/過度活躍症，請註明學生在醫護(如與服藥相關的事宜)/精神健康方面需要關
注的地方 (如適用)：
__________________________________________________________________________________________________
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3. 學生曾否接受智力評估或讀寫能力評估? 曾(請繼續回答(a) 至 (b))  否

(a) 智力評估 (如適用)
i. 評估人員： *教育心理學家/ 臨床心理學家/其他：____________________________________________________
ii. 評估機構：_______________________________________________________________________________________
iii. 評估工具：______________________________________________________________________________________
iv. 評估結果： (例：全量表智商(FSIQ) _______智能水平: *(例:特優/優異/中上/中等/中下/有限/低弱)
____________________________________________________________________________________________________
(b) 讀寫能力評估 (如適用)
i. 評估人員： *教育心理學家/ 臨床心理學家/其他：____________________________________________________
ii. 評估機構：_______________________________________________________________________________________
iii. 評估工具：______________________________________________________________________________________
iv. 評估結果： 結論是否有讀寫困難? 是 否

(乙)校內的服務
學生是否在校內正接受以下服務?
有 (言語治療 職業治療 個別學習計劃 加強輔導教學 其他：____________ )
 沒有
如有，請註明接受服務的時期及服務頻率：_____________________________________________________________

(丙) 學習情況
1. 出席情況
 從未或很少缺課  常常缺課 [請填寫下表並附上出席記錄]
缺席日數： 遲到日數： 早退日數：
 P a g e | 56

2. 學習表現
最近一次的測驗/考試成績 [時段：_______年______月______日至________年______月______日期間]：

中國語文：_____/____ 英國語文： _____/____ 數學：_____/____ 級名次/人數：_____/____

3. 老師對學生上課表現的評語及觀察：
班主任： 中文老師： 英文老師： 數學老師： 其他科目的老師(如適用)：

(丁) 社交活動
1. 在校內是否有擔任的職位? 是 (請填寫下表，可選多項) 否
□班長 □風紀 / 學長 □班會職員
□服務生 （請註 □學會幹事（學會名 □其他：_____________________
明: ） 稱： ）

2.在校內是否有參與課外活動 ? 是 (請填寫下表，可選多項) 否
□宗教活動 □興趣班（請註明： ） □學會活動（請註
明： ）
□義工活動 □制服團體（請註 □其他：_____________________
明： ）

3. 在校內有穩定的朋友圈子? □是 □否 □不清楚

4. 學生在校內的自由時間(如：小息/午休時)通常會選擇做甚麼活動?_______________________________________

5. 學生有甚麼強項/喜好? ______________________________________________________________________________

(請在適當的空格加)
* 請刪去不適用者
 P a g e | 57

沒有駐校社工支援的小學，請學生輔導老師(SGT)或學生輔導主任(SGO)填寫以下(戊)部：
(戊) 家庭背景資料及狀況
直系/同住的家庭成員 (請備註欄內用"+"註明非同住的直系家庭成員)：
姓名 與學生關係 年齡 教育程度 職業 備註

學生父母的婚姻狀況：□良好/完整 □分居 □離婚 □喪偶 □不清楚 □其他(請註明)：__________________

家長的管教模式 _______________________________________________________________________________________
學生主要由_________________照顧日常生活，由________________指導學習，有心事會與______________分享。
學生在家中作息的時間 ________________________________________________________________________________
_______________________________________________________________________________________________________
其他影響學生精神狀況的家庭因素(如父母的健康、精神、居住環境、財政狀況、婚姻關係、家庭成員之間的關係、
家庭有否其他支援等)：
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
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第二部分：學生在學校的適應情況 (此部份建議由學校統籌人員與相關老師共同填寫。如有需要，可諮詢學校社
工或/及校本教育心理學家。)
請根據學生在過去一個月的情況，填寫下列各項(請在適當的空格加)
*「病發前」是指學生的精神病患徵狀出現前的一般表現
1. 學習方面
與同齡學生比較
較好 相若 稍弱 明顯較弱
1.1 專注力    
1.2 記憶力    
1.3 組織能力    
1.4 處理速度    
1.5 學業成績    
1.6 學習態度/動機    
與病發前比較
有進步 相若 少許退步 明顯退步 不清楚
1.1 專注力     
1.2 記憶力     
1.3 組織能力     
1.4 處理速度     
1.5 學業成績     
1.6 學習態度/動機     
備註

2. 適應學校常規方面
經常 間中 甚少 從不
2.1 能根據學校時間表準時回校上 現況    
課 病發前      不清楚
2.2 能完成整天課堂 （不需早退） 現況    
病發前      不清楚
2.3 能遵守校規 現況    
病發前      不清楚
2.4 能跟從教師的課堂指示 現況    
病發前      不清楚
2.5 能在指定時間內完成堂課 現況    
病發前      不清楚
2.6 能準時交齊家課 現況    
病發前      不清楚
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經常 間中 甚少 從不
2.7 能獨立工作，無須別人協助 現況    
病發前      不清楚
2.8 小組討論時，能與同學進行有 現況    
效的溝通 病發前      不清楚
備註

3. 社交適應方面
經常 間中 甚少 從不
3.1 與朋輩關係融洽 現況    
病發前      不清楚
3.2 與老師關係良好 現況    
病發前      不清楚
3.3 參與朋輩間的社交活動 現況    
病發前      不清楚
3.4 參與學校的群體活動 現況    
病發前      不清楚
3.5 對他人批評較為敏感 現況    
病發前      不清楚
3.6 害怕與人溝通或互動 現況    
病發前      不清楚
備註

4. 行為/情緒適應方面
經常 間中 甚少 從不
4.1 發脾氣 現況    
病發前      不清楚
4.2 哭泣 現況    
病發前      不清楚
4.3 表現緊張 現況    
病發前      不清楚
4.4 表現焦慮 現況    
病發前      不清楚
4.5 鬱鬱寡歡 現況    
病發前      不清楚
4.6 上課時打瞌睡 現況    
病發前      不清楚
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經常 間中 甚少 從不
4.7 出現妄想或幻覺 現況    
病發前      不清楚
備註

5. 個人自理方面
經常 間中 甚少 從不
5.1 能保持校服儀容整潔 現況    
病發前      不清楚
5.2 能帶齊所需的物品 現況    
病發前      不清楚
5.3 能妥善收拾個人物品 現況    
病發前      不清楚
備註

6. 高危行為方面
6.1 自殘行為 沒有 有(請闡釋)

6.2 自殺行為 沒有 有(請闡釋)

6.3 暴力傾向 沒有 有(請闡釋)

6.4 其他 沒有 有(請闡釋)

備註

完成評估所需時間：______________________________________________________

Appendix 7: Assessment Form -- School Social Work Service
Reference No.:
Name of the Student:
Sex / Age:
School:
Class Level:
Known Case of School Social Worker:
If yes, please specify:
Source of Referral:
 School Principal/ Vice-Principal
 Discipline Teacher
 Guidance Teacher
 Teacher
Reason(s) for Referral:
Genogram:
P a g e | 61
 No  Yes, since: ___________________
 Educational Psychologist  Other welfare agency
 Student Guidance Officer  Self-referral
 Schoolmate  Identified by school social worker
 Client’s parent/ family members  Others_______
Key care taker:
 Birth mother/ father
 Step mother/ father
 Grandma/ grandpa
 Out of home placement
 Adoptive parents
 Others:__________________
Marital status of birth parents:
 Intact
 Separated
 Divorced
 Deserted
 Widowed
 Cohabitating
Family monthly income:
$__________for____person
Bread winner:
 Birth mother/  father
 Step mother/  father:
 Others:______________
 On CSSA
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Psychosocial Assessment
Please  or  the *item(s) that can describe the characteristics of the client for formulation of the
social care plan.
I. FAMILY
1. Accommodation (□ Not known)
 Public housing estate  Reside in relative’s home
 Self owned/ rented private housing  In/ waiting for residential care service
 Home ownership scheme  Others:__________________________
 Cramped apartment (e.g. sub-divided flat)
2. Financial difficulties (□ Not applicable/ □ Not known)
 On CSSA  Unemployment of father/ mother
 Low family income  Need financial support from: _____________
 Unstable income  Others:__________________________
3. Parent/child relationship (□ Not applicable/ □ Not known)
 Secure: Strong attachment  Avoidant: Insecure attachment
(Child can depend on parents and knows what to expect (Child knows he/she cannot depend on parents and
from them). learns to take care of oneself).
 Ambivalent: Insecure attachment  Disorganized: Disorganized attachment
(Child’s needs are only sometimes met and look for (Child can’t predict parent’s reaction and doesn’t know
security needs sometimes fulfilled). what to expect from them).
4. Parenting / childcare (□ Not applicable/ □ Not known)
* Parents are generally capable in parenting/ have difficulty over parenting
Parents need support over:
 understanding child/ adolescent’s development  affective skills
 boundary setting skills  family management skills
 instructive skills  Others:__________________________
 contract setting skills
5. Parents' marital relationship
5A Support vs. conflict (□ Not applicable/ □ Not known)
Support  High  Low
Conflict  High  Low
5B Other marital issues (□ Not applicable/ □ Not known)
 Divorced  Frequent quarrels/ fights
 Separated and plan for divorce (reason: finance/ parenting/ in-law/ household issue/
 Extra-marital affairs others:___________)
 Others:__________________________
6. Sibling relationship (□ Not applicable/ □ Not known)
 Supportive relationship  Sibling rivalry
 Apathetic relationship  Enmeshed relationship
 Hostile relationship  Others:__________________________
 Manipulative relationship
7. Family crisis affecting client’s recent functioning (□ Not applicable/ □ Not known)
Nature of crisis: Family coping status:
 Subtle and gradual  Family disorganized
 Abrupt and dramatic  Family resists change to meet the demands of
 Marital/ financial/ mental/ health problems developmental crisis
of_________________________________  Shift roles of responsibility within family
 Death of family members  Day-to-day hassles piled up and family member stressed
(Occurrence:_____________/ Relationship with out (e.g. sleeplessness, lack of appetite, memory lapses,
client: __________________________) depression and anxiety)
 Others:__________________________  Unrecognized strengths and abilities of family revealed
 Can't get "unstuck" and need professional help
 Others:__________________________
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8 Problems related to student's other close family members (□ Not applicable/ □ Not known)
 Financial problem (unstable income/ victim of loan  Not known whereabouts of client’s ____________
shark) of client’s ___________________________  In bereavement after a loss of client’s __________
 Health problem (physical/ emotional/ mental/  Others:__________________________
hospitalization) of client’s ___________________
9 Frequent staying out overnight/after midnight (□ Not applicable/ □ Not known)
 Stay away from danger at home  Stay at home of classmate/ friend
 With the company of boyfriend/ girlfriend  Stay outdoor outside (e.g. pier/ harbour front) alone/
 Because of parent-child relationship with peers
 Because of sibling relationship  Stay indoor outside (e.g. 24 hour open restaurants,
 Because of dissatisfaction in schooling internet bar, karaoke etc.) alone/ with peers
 Under peer influence  Others:__________________________
10 Missing/running away from home (□ Not applicable/ □ Not known)
 Because of parent-child relationship  With the company of boyfriend/ girlfriend
 Because of sibling relationship  Stay away from danger at home
 Because of dissatisfaction in schooling  Others:__________________________
 Under peer influence
II. PEER RELATIONSHIP
11 Social skills in relating to peers (□ Not known)
* Generally good social skills/ Not satisfactory social skills
Client may need support over:
 Poor/ Lack of listening skills  Difficult/ Fail to recognize others’ point of view
 Poor/ Lack of peer resistance/ negotiation skills  Difficult/ Fail to understand other’s feeling
 Poor/ Lack of anger management skills  Others:__________________________
 Poor/ Lack of conflict management skills
12 Conflicts with peers (□ Not applicable/ □ Not known)
Types of conflict:
 Individual quarrel/ fights with peers  Conflicts involved bullying (repeated and intentional
 Conflicts among groups of friends actions involving power imbalance)
 Others:__________________________
13 Courtship/dating (□ Not known)
 Not in any intimate relationship
 In an intimate relationship (*Generally satisfactory/ Have relationship problem: please elaborate)
 Conflict (*High/ low/ frequent/ occasional)  Disapproval from teachers
 On the verge of breakup  Disapproval from parents
 Third-party involvement  Others:___________________________
14 Problems in relating to opposite-sex peers (□ Not applicable/ □ Not known)
 Inappropriate manner/ conduct  Gender bias
 Misinterpret the attentions of the opposite sex  Others:__________________________
 Get physically involved too soon
15 Undesirable peer influence (□ Not applicable/ □ Not known)
Associate with peers:
 with bad habits/ hobbies  alienate other people (e.g. family members) from the
 with high risk behaviour client
 Others:__________________________
16 Social activity related to information technology (□ Not applicable/ □ Not known)
 Use social media to enrich social life  Bully others online
 Give out contact details online  Violate others’ privacy rights
 Join adult-only social networking sites and give false  Navigate terrorist related website
personal information  Navigate pornographic website
 Arrange face to face meeting with an online contact  Others:__________________________
alone
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III. SCHOOL-RELATED ISSUES

17 School attendance (□ Not known)
* Normal school attendance/ Relatively higher rates of absence/ Habitual missing from school
Possible reasons for poor school attendance:
 Associated with gang during truancy  Others:___________________________
 Staying at home during truancy
18 Behaviors in school (□ Not known)
* Very well behaved/ Generally well behaved/ Not well behaved
Please elaborate:
 Tardiness  Speak foul languages
 Smoke  Damage school property
 Cheat  Bully schoolmates
 Restless/ Shout and yell in class Others:___________________________
19 Adjustment to school (□ Not applicable/ □ Not known)
* Generally adjusted/ Not well adjusted
Possible reasons for difficult adjustment:
 Unfamiliar with school environment and regulation  Have language/ cultural barriers
 Cannot catch up with academic requirement  Feel unfairly/ unjustly treated
 Lack of friends  Others:___________________________
20 Teacher-student relationship (□ Not known)
* Very good/ Satisfactory/ Moderate/ Distant/ Poor  Not trustful/ inharmonious relationship
 Trustful/ harmonious relationship (Possible reasons:
(Possible reasons:  Cannot communicate  Inappropriate manner
 good communication  appropriate manner   Ignorance of advice/ instructions
Others ________________________)  Others )
21 Motivation to study (□ Not known)
* Highly motivated/ Generally motivated/ Not quite motivated
Possible reasons for lack of study motivation:
 Discouraged by poor academic performance  Unfavorable study environment (e.g. high distraction
 Discouraged by an unrealistic goal and poor access to learning device)
 Find little interest/ meaning/ achievement in study  Other physical, mental, personal or relationship
 Individual education needs cannot be catered problems that affects motivation (Please elaborate:
 Occupied by part-time job _______________________________________)
22 Career choice/further study (□ Not applicable/ □ Not known)
 Planning for further study  Confusion about choice of further study/ career
 Planning for future career development  Others:___________________________
 Looking for a school/ job

IV. DEVELOPMENTAL ADJUSTMENT

23 Self-esteem (□ Not known)
 Feel very positive/ positive/ negative/ very negative about oneself
 Feel very positive/ positive/ negative/ very negative about life in general.
 Feel very able/ able/ inadequate/ very inadequate to deal with life's ups and downs.
 Others:___________________________
24 Self-identity
24A Identity formation (□ Not known)
Interest to explore developmental alternatives  High  Low
Efforts to commit in relevant activities  High  Low
24B Identity confusion (□ Not applicable/ □ Not known)
 Gender role  Social role (e.g. religious/ political)
 Family role  Others:___________________________
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25 Adjustment to physiological change of adolescents (□ Not known)

* Generally adjusted/ Not well adjusted
Areas of difficult adjustment:
 Menstruation  Change in voice
 Change in physical appearance  Wet dreams
 Body odor and acne  Others:___________________________
26 Adjustment to physical disability/ illness or mental disorders (□ Not applicable/ □ Not known)
Type of disability: Area of adjustment:
 Inborn  Self-care and home living
 Caused by recent crisis/ accident  Studies
 Social life
 Others:___________________________

V. EMOTION/MENTAL HEALTH
27 Emotionally unstable (□ Not applicable/ □ Not known)
 Persistently in low mood  Drug-induced mood swing
 Crying often  Panic attack (last 5-20 minutes, with breathlessness, a
 Easily agitated racing heartbeat and trembling)
 Emotional outburst at school/ family  Others:__________________________

28 Inhibited/withdrawn behaviour (□ Not applicable/ □ Not known)

 Spend significant time alone  Unable to interact with family members
 Avoid initiation and maintenance of interpersonal  Unable to interact with others
relationships  Display of non-normative or unacceptable behavior
 Unable to get out from home (e.g. aggression, impulsivity, and social immaturity)
 School refusal  Others:___________________________
 Negligence on personal hygiene

29 Unmanageable anxieties in stressful situation (□ Not applicable/ □ Not known)

 Sleep problems Possible source of stress:
 Eating problems  Examination
 Physical symptoms (e.g. headache, stomachache)  Extra-curricular activities
 Avoid social activities  Loss of friend(s)
 Affect school performance  Bullying
 Emotional outburst  Family crisis
 Excessive need for reassurance  Others:__________________________

30 Client’s perception of his/her own mental health needs

30A. Client’s self-understanding of mental health problems/ SEN
 Full  Partial  Little  Not known
30B. Client’s acceptance of mental health problems/ SEN
 Full  Partial  Little  Not known
30C. Family’s attitude toward client’s mental health problems/ SEN
 Supportive  Receptive  Ambivalent  Rejecting
30D. Client’s receptiveness to treatment service
(Service type: psychiatric/ medical/ psychological/ others:_____________)
 Receptive  Ambivalent  Rejecting  Not known
30E. Client’s receptiveness to social work service
 Receptive  Ambivalent  Rejecting  Not known
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31 Attempted suicide/ suicidal tendency (□ Not applicable/ □ Not known)

 Recent ideation and intent
 Recent plan (date:______/ means:_______)
 Recent attempt (date:______/ means:_______)
 Previous suicide attempt(s)
(date:____________/ means:_____________)
 Self harm (e.g. hand slashing)
(Please indicate frequency and means:
________________________________________)
 Impulsivity and poor self control
 Hopelessness
 Recent losses – physical, financial, personal
(date:____________/ loss:______________)
 Family history of suicide (Relationship with
client:___________/ means:_____________)
 Others:___________________________

32 Post-traumatic emotional adjustments

 Not applicable  Denied  Not known  Remarks:_________________

Services Rendered by School Social Worker

 Counseling to students  Referral to IFSC
 Counseling to parents  Referral to FCPSU
 Home Visit  Referral to clinical psychologist
 Collateral Contacts  Referral to police
 Mutual support/ Treatment group  Referral to other welfare agency
 Mutual support/ Treatment program  Others:___________________

Other Service Provided by Same/Other Organizations

 Probation/ Community Support Service Scheme  Clinical Psychologist Service
 Family Service  Psychiatric Service
 Medical Social Service  Residential Service
 Children and Youth Services  Police Supervision
 Social Security  Others:___________________
 EDB Special Education Service/ Education
Psychologist Service
Remarks:

Time Spent on Completing this Assessment Form:

Prepared by: Approved by:

(Signature) (Signature)

Name: Name:

Post: Post:

Date: Date:
 P a g e | 67

Appendix 8: Integrated Assessment and Care Plan (For Students known to HA C&A
Psychiatric Services)

Serial No : Sample 001

Integrated Assessment and Care Plan
Date : 01/01/2017
(For Students known to HA C&A Psychiatric Services)

Student Name: Happy Hoi-Sum CHU Age/Sex: 12/F

School:_ St.xxxxx secondary school Class: F1
Diagnosis: GAD/OCD _ Follow-up Clinic: YMTC&A SOPD
Parent/Legal Guardian (Relationship): Grace MA (mother)
Reason for participating in the SMHSS: Poor concentration in class due to repeated hand-washing behaviour_

INTEGRATED ASSESSMENT – 5PS

Presenting 1. Repeatedly go hand-washing during lessons, increased frequency in these 2 months, up to twice a lesson

Problems 2. Unable to concentrate during lessons

3. Express feeling stress and anxiety when going to school, especially these 2 months

4. Frequent sick leave ( 6 days in 2 months) and frequent late to school ( 5-6 times this month)

Predisposing 1. Mother has history of depression followed up in HA Psychiatry SOPD ○

1

Factors * 2. Frequent family conflicts between mother and father (may be due to her mother mental illness) ○
1

Precipitating 1. Mother recent relapse of mental illness ( 1 month ago) and admitted to psychiatric unit for 2 weeks ○
1

Factors * 2. Will have school final exam 1 months later ○

2

Perpetuating (Factors or conditions that maintain the disabling symptoms in an individual)

Factors * 1. Stressful event at school ○

2

2. Persistent family conflicts ○

1

3. Poor control of her mother’s mental illness ○

1

Protective 1. Good school performance (ranked 15/34 in class) despite the presenting problems ○
2

Factors * 2. Good social support with many close friends/ classmates at school ○
3

3. ○
Supportive parents and grandparents
1

INTEGRATED CARE PLAN

Objectives 1. To tackle the acute exacerbation of OCD

2. To monitor and tackle her emotional swing pre and post examination

3. To reduce the stress factors from family

 P a g e | 68

Interventions (Schools can refer to Appendix 10 for examples) Examples:

in multi-
disciplinary Interventions By

approach 1. Communicate with parents/legal guardians on the care plan Designated psy. nurse

2. School Support Team will communicate with her class teachers to give School Support Team

allowance on the frequency to go to toilet and return time for school

homework in these 2-3 months during the progress of our interventions.

3. School-based EP will arrange intervention sessions and assessment on School-based EP

her academic performance

4. Teachers may arrange extra tutorial sessions (may be in groups) to Teachers

support her academic needs.

5. School social worker will arrange interviews and counselling with her School social worker

family members and explore the needs and aim to reduce the conflicts

between her parents

6. School social worker will liaise with the MSW( who follows her mother School social worker

mental problem) to have closer monitoring on her mother’s mental

health condition.

7. Designated psy. nurse will arrange appropriate intervention for the Designated psy. nurse

students for the recent flare up of illness and will arrange earlier SOPD

follow up if her mood problem worsen.

8. Refer Clinical Psychologist for further Assessments. Designated psy. nurse

Etc….

Other parties  HA MDT team:  IFSC/ISC

involved in  MSSU  FCPSU  Parents/Legal Guardians  Other:
case
conference
Target timeline 1. Review condition after 4 months
2. Next meeting in July 2017

* Please specify the aspect of the factors into 1) family related (including Family History);
2) school related factors; 3) peer related factors; 4) self-issues; and 5) others.
 P a g e | 69

Evaluation/ Case was discussed on 5/7/2017with multidiscipline

Progress
(Please specify the
following Remarks:
outcomes:
emotional & Interventions (discussed on 5/7/2017) By Will Will Completed
behavioural
changes; academic follow continue
achievement;
utilisation rate of
hospital services; up
change in family


relationships; 1 Communicate with parents/legal guardians Designated
change in parental
stress; change in on the care plan psy. nurse
knowledge &
attitude etc ) 2 School Support Team will communicate with School Support

her class teachers to give allowance on the Team

frequency to go to toilet and return time for

school homework in these 2-3 months


during the progress of our interventions.

3 School-based EP will arrange intervention School-based

sessions and assessment on her academic

performance
EP

4 Teachers may arrange extra tutorial sessions Teachers

(may be in groups) to support her academic

needs.

5 School social worker will arrange interviews School social

and counselling with her family members

and explore the needs and aim to reduce

worker

the conflicts between her parents

6 School social worker will liaise with the School social


MSW( who follows her mother mental worker

problem) to have closer monitoring on her

mother’s mental health condition.

7 Designated psy. nurse will arrange Designated

appropriate intervention for the students for psy. nurse

the recent flare up of illness and will arrange

earlier SOPD follow up if her mood problem


worsen.


8 Refer Clinical Psychologist for further Designated

Assessments. psy. nurse

Progress:
 P a g e | 70

Serial No :
Date : / /
Integrated Assessment and Care Plan
(For Students known to HA C&A Psychiatric Services)

Student Name: Age/Sex: / School: Class:

Diagnosis: _ Follow-up Clinic:
Parent/Legal Guardian (Relationship):
( )
Reason for participating the SMHSS:
INTEGRATED ASSESSMENT – 5PS
Presenting 1.

Problems

Predisposing 1.

Factors *

Precipitating 1.

Factors *

Perpetuating (Factors or conditions that maintain the disabling symptoms in an individual)

Factors * 1.

Protective Factors 1.
*

INTEGRATED CARE PLAN

Objectives 1.
 P a g e | 71

Interventions in (Schools can refer to Appendix 10 for examples)

multi-disciplinary Interventions By

approach 1. Communicate with parents/legal guardians on the care plan

2.

3.

4.

5.

6.

7.

8.

Other parties  HA MDT team:  IFSC/ISC

involved in case  MSSU  FCPSU  Parents/Legal Guardians  Other:
conference

Target timeline 1.
 P a g e | 72

Evaluation/ Case was discussed on _Date _____with multidiscipline

Progress
(Please specify the
following outcomes: Remarks:
emotional &
behavioural changes; Interventions (discussed on_(previous By Will Will Completed
academic
achievement; meeting date_) follow continue
utilisation rate of
hospital services; up
change in family
relationships; change 1
in parental stress;
change in knowledge
& attitude etc. )
2

4.

Progress:

Time spent on completing this integrated assessment and care plan:

* Please specify the aspect of the factors into 1) family related (including Family History);
2) school related factors; 3) peer related factors; 4) self-issues; and 5) others.
 P a g e | 73

Appendix 9: Integrated Assessment and Care Plan (For Students not known to HA
C&A Psychiatric Services)
Serial No : Sample 002
Integrated Assessment and Care Plan Date : 01/01/2017

(For Students not known to HA C&A Psychiatric Services)

Student Name: Blue Mo Sum KEI Age/Sex: 15/M

School: _XXXXXX secondary school Class: F3B
Diagnosis (if applicable): GAD/OCD Follow-up Clinic: Clinic – Private Psychiatrist Dr CHAN
Parent/Legal Guardian (Relationship): Mrs SK YIP (mother)
Reason for participating in the SMHSS: Poor concentration in class due to repeated hand-washing behaviour

INTEGRATED ASSESSMENT – 5PS

Presenting 1. Repeatedly go hand-washing during lessons, increase frequency in these 2 months, up to twice a lesson

Problems 2. Unable to concentrate during lessons

3. Express feeling stress and anxiety when going to school, especially these 2 months

4. Frequent sick leave ( 6 days in 2 months) and frequent late to school ( 5-6 times this month )

Predisposing 1. Mother has history of depression followed up in HA Psychiatry SOPD ( information by social worker) ○
1

Factors * 2. Frequent family conflicts between mother and father (may be due to her mother mental illness ○
1

Precipitating 1. Mother recent relapse of mental illness ( 1 month ago) and admit to psychiatric unit for 2 weeks

Factors * ( information by social worker) ○

1
2. Will have school final exam 1 months later ○
2

Perpetuating 1. Stressful event at school○

2

Factors * 2. Persistent family conflicts ○

1

3. Poor control of her mother’s mental illness ○

1

Protective 1. Good school performance (ranked 15/34 in class ) despite the presenting problems ○
2

Factors * 2. Good social support with many close friends/ classmates at school ○
3

3. Supportive parents and grandparents ○

1

INTEGRATED CARE PLAN

Objectives 1. To tackle the acute exacerbation of OCD

2. To monitor and tackle her emotional swing pre and post examination

3. To reduce the stress factors from family

 P a g e | 74

Interventions in (Schools can refer to Appendix 10 for examples) Examples

multi- disciplinary
approach
Interventions By

1. Communicate with parents/legal guardians on the care plan School social worker

2. School Support Team will communicate with her class teachers to give School Support Team

allowance on the frequency to go to toilet and return time for school

homework in these 2-3 months during the progress of our interventions.

3. School-based EP will arrange intervention sessions and assessment on School-based EP

her academic performance

4. Teachers may arrange extra tutorial sessions (may be in groups) to Teachers

support her academic needs.

5. School social worker will arrange interviews and counselling with her School social worker

family members and explore the needs and aim to reduce the conflicts

between her parents.

6. School social worker will liaise with the MSW (who follows her mother School social worker

mental problem) to have closer monitoring on her mother’s mental

health condition.

7. School social worker will convey the message “advance the follow up School social worker

appointment to private psychiatrist, may need adjustment of medication/

arrange appropriate intervention to the student and will also advise him

to get a written medical report from the private psychiatrist as a

reference for the case conference and the care plan formulation.

8. Refer Clinical Psychologist for further Assessments. Designated psy. nurse

Etc….

Other parties  HA MDT team:  IFSC/ISC

involved in case  MSSU  FCPSU  Parents/Legal Guardians  Other:
conference
Target timeline 1. Review condition after 4 months
2. Next meeting in July 2017
 P a g e | 75

Evaluation/ Case was discussed on _Date _____with multidiscipline

Progress
(Please specify the
following outcomes: Remarks:
emotional & behavioural
changes; academic Interventions (discussed on_(previous By Will Will Completed
achievement; utilisation
rate of hospital services; meeting date_) follow continue
change in family
relationships; change in
parental stress; change in up
knowledge & attitude
etc. ) 1

4.

Progress:
 P a g e | 76

Serial No :
Integrated Assessment and Care Plan Date : / /

(For Students not known to HA C&A Psychiatric Services)

Student Name: Age/Sex: /

School: Class:
Diagnosis (if applicable): _ Follow-up Clinic:
Parent/Legal Guardian (Relationship): ( )
Reason for participating in the SMHSS:

INTEGRATED ASSESSMENT – 5PS

Presenting Problems 1.

Predisposing 1.

Factors *

Precipitating 1.

Factors *

Perpetuating (Factors or conditions that maintain the disabling symptoms in an individual)

Factors * 1.

Protective Factors * 1.

INTEGRATED CARE PLAN

Objectives 1.
 P a g e | 77

Interventions in (Schools can refer to Appendix 10 for examples)

multi-disciplinary
approach Interventions By

1. Communicate with parents/legal guardians on the care plan

2.

3.

4.

5.

6.

7.

8.

Other parties  HA MDT team:  IFSC/ISC

involved in case  MSSU  FCPSU  Parents/Legal Guardians  Other:
conference
Target timeline 1.
 P a g e | 78

Evaluation/ Progress Case was discussed on ___Date_____with multidiscipline

(Please specify the
following outcomes:
emotional & behavioural
changes; academic Remarks:
achievement; utilisation
rate of hospital services; Interventions (discussed By Will follow Will Completed
change in family
relationships; change in on_(previous meeting date_) up continue
parental stress; change in
knowledge & attitude etc. ) 1

4.

Progress:

Time spent on completing this integrated assessment and care plan:

* Please specify the aspect of the factors into 1) family related (including Family History);
2) school related factors; 3) peer related factors; 4) self-issues; and 5) others.
 P a g e | 79

Appendix 10: Examples of Learning Support Strategies for Students with Mental
Health Needs (in Chinese only)
為有精神健康需要的學生提供的學習支援策略 (例子)
學校可參考以下例子，並須按個別個案情況訂定合適的學習支援策略，協助訂立「綜合評估及護理計劃」
(Integrated Assessment and Care Plan) 。
學習支援：
1. 班主任、社工、醫護人員與家長及學生保持緊密溝通，盡量確保學生準時覆診及了解其康復情況
2. 鼓勵學生保持良好的生活規律
3. 安排合適的課外活動
4. 優化課堂教學
i. 調節教學策略
a. 運用多元化的教學技巧和互動的課堂活動，以提升學生的學習動機
b. 留意學生的參與程度及調節課業要求，以免學生承受太大壓力
c. 提問前先給予預告，讓學生有充足的思考時間
d. 給予學生提示及充足的回應時間
e. 增加正面回饋
ii. 課堂內外的支援
a. 預先提供課堂的學習資料，例如給予學生課本章節的學習重點
b. 為學生預備筆記，減少學生抄寫的需要，亦減輕學生在記憶、專注及組織上的負荷
c. 容許學生在課堂內使用額外的學習工具，例如錄音筆、計時器等
d. 安排朋輩支援，以便在上課時給予學習或情緒上的支援
e. 為學生預備教材/工作紙，幫助組織資料，例如視覺組織圖、寫作框
iii. 家課、測考及其他調適
a. 彈性上課時間/另設上課時間表，例如先安排學生參與自己可應付的課堂
b. 課程調適 (例如 ：深淺程度、施教的先後次序)
c. 功課調適 (例如： 深淺程度、功課量、彈性處理交功課的日期)
d. 測考調適 (例如：延長考試時間、安排獨立房間讓學生個別應考)
5. 定期會見學生，以便了解其需要及監察進展
6. 為學生安排小組輔導/訓練，(例如：功課輔導、情緒輔導、社交訓練、學習技巧訓練，如閱讀、記憶、計劃
及組織資料的技巧)
7. 訂定及推行個別學習計劃
8. 為學生安排個別輔導 (例如 ：功課輔導 /情緒輔導)
其他
1. 安排一個安全、寧靜地方讓學生在有需要時稍作休息
2. 安排學校人員在有需要時帶學生離開課室到休息室休息
3. 家庭支援
* 更多例子可見於《認識及支援有精神病患的學生—教師資源手冊》的第二章及附錄一
https://www.edb.gov.hk/attachment/tc/student-parents/crisis-management/about-crisis-management/Resource_Handbook_on_MI_Chi.pdf
 P a g e | 80

Appendix 11: Selected Risk and Protective Factors for Mental Health of
Children and Adolescents

Selected Risk and Protective Factors for Mental Health of Children and Adolescents
Domain Risk Factors (Predisposing /Precipitating Factors) Protective Factors
Biological  Exposure to toxins (e.g. tobacco and  Age-appropriate physical
alcohol) in pregnancy development
 Genetic tendency to psychiatric  Good physical health
disorder  Good intellectual functioning
 Head trauma
 Hypoxia at birth and other birth
complications
 HIV infection
 Malnutrition
 Other illnesses

Psychological  Learning disorders  Ability to learn from experiences

 Maladaptive personality traits  Good self-esteem
 Sexual, physical and emotional abuse  High level of problem-solving
and neglect ability
 Difficult temperament  Social skills

Social
a) Family  Inconsistent care-giving  Family attachment
 Family conflict  Opportunities for positive
 Poor family discipline involvement in family
 Poor family management  Rewards for involvement in
 Death of a family member family

b) School  Academic failure  Opportunities for involvement in

 Failure of schools to provide an school life
appropriate environment to support  Positive reinforcement from
attendance and learning academic achievement
 Inadequate/inappropriate provision  Identity with a school or need for
of education educational attainment

c) Community  Lack of “community efficacy”  Connectedness to community

(Sampson, Raudenbush & Earls, 1997)  Opportunities for constructive
 Community disorganisation use of leisure
 Discrimination and marginalisation  Positive cultural experiences
 Exposure to violence  Positive role models
 Lack of a sense of “place” (Fullilove,  Rewards for community
1996) involvement
 Transitions (e.g. urbanisation)  Connection with community
organisations including religious
References organisations
Source: Mental Health Policy and Service Guidance Package: Child and Adolescent Mental Health Policies and Plans, World
Health Organization, 2005
 P a g e | 81

Appendix 12: Standard brief assessment – HA designated psychiatric nurse

(for cases not known to HA C&A psychiatric services)

Name: _____________________ ( )
Student Mental Health Support Scheme
HKID: __________________ Sex/Age: _____________
Standard Brief Assessment Form DOB: _________________Case no.________________

Cluster:  KEC  KWC  HKWC  NTEC  NTWC

Date of Assessment: __________________________Referred by: ___________________________ on _______________

Reason of Referral: __________________________________Informant:_________________________________________

Name of School:______________________________________________________ Grade Level:____________________

1. Genogram:

2. General Health

Appetite:  No Problem  Change in Appetite ( Increased  Decreased)

Sleep Problem:  No  Yes (Please specify: _______________________________________________________)

Elimination:  Normal  Diarrhoea  Constipated  Incontinent (Urinary/Faecal/Double)

Physical Discomfort:  No  Yes (Please specify: _________________________________________________)

3. Behaviour

Eye-contact:  Sustained  Brief  Fleeting  Poor  Avoidant

Interaction:  Over-friendly  Co-operative  Passive  Avoidant  Withdraw

Verbal Expression:  Spontaneous  Fair  Lack of reciprocity  Weak  Mute Others(_____________)

Perspective Taking Ability:  Good  Fair  Weak

Strengths / Hobby: __

Loss of interest:  No  Yes (Please specify: _____________________________________________________)

 P a g e | 82

Activities of Daily Living:  Independent  Prompted  Dependent  Lack of Motivation

School attendance:  Regular  Irregular  Refuse to Attend (_______________________________)

Academic Performance:  Good  Above Average  Average  Below Average  Poor  N/A

- Any Deterioration:  No  Yes (Please specify: ______________________________________________)

Organisation Skill:  Good  Average  Fair  Poor  Deteriorated

Participation in Leisure Activities:  Active  Passive  Withdraw  Lack of Motivation

Time Management:  Well-planned  Fair  No Planning  Poor  Deteriorated

Behavioural Problem:  No  Yes (Please specify: ___ ___ _ ______

________________________________________________________________)

4. Emotion / Cognition
Mood:  Euthymic  Anxious  Depressive  Elated  Irritable  Others (____________________)

Affect:  Congruent  Incongruent  Blunt  Labile  Exaggerated  Others (____________)

Emotional Control:  Good  Fair  Poor  Impulsive (Please specify: _________________________)

Speech:  Coherent  Relevant  Incoherent  Irrelevant  Mute  Others (______________)

Attentiveness:  Attentive  Inattentive  Distractible  Disinterested  Pre-occupied

Perception of Self:  Self-confident  Satisfied with Self  Lack of Confidence  Worthlessness

Perception of Future:  Hopeful  Well-planned  No Planning  Hopeless  Others (_________)

Hopes and Dreams: ____________________________________________________________________________

Way of Coping:  Seek Support (from_______________________________)  Willing to face the Problem

 Avoidant  Blaming: Self / Other:_____________________  Self-harmed

 Others (_______________________________________________________________________)

Hallucination:  Denied  Auditory  Visual  Olfactory  Tactile  Gustatory

Delusion:  Denied  Persecution  Reference  Hypochondriasis  Guilt  Grandiosity  Love

Insight:  Intact  Partial  No

(*Delete as appropriate)
5. Inter-personal / Social Relationship
Relationship with: - *Father/Carer ( )  Good  Satisfactory  Fair  Poor  N/A

- *Mother/Carer ( )  Good  Satisfactory  Fair  Poor  N/A

Relationship with: - *Siblings ( )  Good  Satisfactory  Fair  Poor  N/A

Relationship with Schoolmates/Peers  Good  Satisfactory  Fair  Poor  N/A

Relationship with Teachers  Good  Satisfactory  Fair  Poor  N/A

 P a g e | 83

6. Risk Level
Suicidal Ideation:  Denied  Fleeting  Vague  Concrete

Warning Signs of Suicidal Intention:  N.A.D.  threatening to kill own self  Suicidal Notes

 Deliberate Self-harm  Giving away personal possessions

Suicide Plan:  No  Yes (Please specify: _ ___ _ ______

________________________________________________________________)

Suicidal Attempt:  No  Yes (Please specify: _ ___ )

Aggression:  No  Verbal  Physical (Please specify: _ __

________________________________________________________)

7. Any medical / psychiatric / psychological / social support service received (If applicable):
* Please supplement if any reports are available. *

_______________________________________________________________________________

_______________________________________________________________________________

8. Medication Taking (If applicable)

Current Medications: as at (Date)

Drug Compliance:  Compliant  Self-adjusting  Doubtful  Non-compliant  Supervised by (_______)

Side Effect:  No  Yes (Please specify: __ _________________________ )

9. Supplementary Information / Observation (If applicable):

________________________________

_______________________________________________________________________________________________

10. Parent’s worries and main concerns (if applicable):

________________________________________________________________________________

________________________________________________________________________________
11. [For Secondary school students only] GAD 7 Score: _________

 Mild (5-9)  Moderate (10-14)  Severe (≥ 15)

[For Secondary school students only] PHQ 9 Score: _________

 Minimal or none (0-4)  Mild (5-9)  Moderate (10-14)  Moderately Severe (15-19)

 Severe (≥20)
 P a g e | 84

12. Intervention
Presence of Suggested Referral to the
Suspected Problem Area(s)
Problem(s) following discipline(s)

1. Any cases require immediate medical examination, Advice to school personnel

medical treatment, pharmacological treatment or to make referral for C&A
hospitalization psychiatric services

2. Behavioral problems ( e.g. ODD / challenging behavior)

that affects daily functions

3. Presence of clinical depressive symptom(s) causing

disturbance to daily functioning (e.g. schooling /daily
living activities/ socialisation) Clinical Psychologist

4. Presence of clinical anxiety symptom(s) (e.g. excessive

fear, avoidance behaviour)

5. Presence of eating disorder symptom(s) (e.g. excessive

concern on body weight and/or shape)

6. Subclinical anxiety and/or depressive mood symptoms ASWO

7. Social welfare Problems SSW & Nurse

8. Presence of active psychotic symptom(s) which affects

EASY & Nurse
daily functioning

9. Problems that are not mentioned in the above set of

Nurse
criteria from item 1-6

Discussed in CAMHS Team:  No  Yes, dated on ____________________________

If yes, recommendation: ___________________________________________________________________________

________________________________________________________________________________
Time spent on completing this integrated assessment and care plan:

Assessment done by: Name:

( Signature)

Assessment done by: Name:

( Signature)
 P a g e | 85

Appendix 12A: Standard Assessment Tool (PHQ-9) (for cases of secondary

school students only)
「醫教社同心協作計劃」
健康狀況問卷 (PHQ-9)

Note: PHQ9 can also be downloaded from the official website:

https://www.phqscreeners.com/sites/g/files/g10049256/f/201412/PHQ9_Traditional%20Chinese%20for%20Hong%20Kong.pdf
 P a g e | 86

Appendix 12B: Standard Assessment Tool (GAD-7) (for cases of secondary

school students only)

「醫教社同心協作計劃」
焦慮自我評估量表 (GAD-7)

Note: GAD-7 can also be downloaded from the official website:

https://www.phqscreeners.com/sites/g/files/g10049256/f/201412/GAD7_Traditional%20Chinese%20for%20Hong%20Kong.pdf
 P a g e | 87

Appendix 13: Guideline to primary schools on printing and distributing of

questionnaire

印製及處理問卷指引

為確保問卷內的資料得以保密及準確分析，請 貴校依以下指引處理問卷。
* 所有問卷均受版權條例保護，如未經授權，請勿自行加印。

校方事前預備及收集問卷指引

1. 請用A4白紙雙面印製問卷，為方便使用電腦計分，請勿隨意更改紙張大小
及請勿使用油印紙。
2. 為保持問卷的完整性，請勿對摺、摺曲或釘裝問卷。

老師派發問卷指引

1. 為保持問卷的完整性，請勿對摺、摺曲或釘裝問卷。
2. 請老師於___月___日派發家長通知書及問卷予學生家長，以便其了解此計劃及
填寫相關問卷。
4. 請老師於___月___日收集所有問卷後，立即保密存放。

~多謝合作 ~
 P a g e | 88

Appendix 14: Assessment form – HA assistant social work officer (Group

Interview) (for cases identified with subclinical anxiety and/or depressive
mood symptoms only and unknown to HA C&A psychiatric services)
Hospital Authority
Student Mental Health Support Scheme
School-Based Screening and Group/Day Program Assessment Form
Cluster:  HKWC  KEC  KWC  NTEC  NTWC
A. Personal Information
Client’s name: (English) (Chinese)
School: Class:
B. Screening
Pre-test Date Questionnaire Total Score: Range (SD) Post-test Date Questionnaire Total Score: Range (SD)
☐ SCAS (Parent) Age Problem ☐ SCAS (Parent)
☐ SCAS (Child ) ☐ SCAS (Child )
C. Group/Individual Interview
Date of Group/Individual Interview: __ / / __
 Parent  Student  Others ( _________________)
Main Presenting Problem:
 Anxiety Symptom  Depressive Symptom  Others:
D. Recommendation
 Suitable for Reason:  Subclinical Anxiety  Subclinical Depressive Mood  Others:
preventive  Accept SMHSS preventive service
service  Group  Day Program  Individual Case (Next FU date / time : at hours)
 Decline SMHSS preventive service
 Discuss in SMHSS case conference
 Others:________________________
Remark:
 Not suitable Reason:  No mood concern
for preventive  Student's symptoms subsided
service  Suspected clinical anxiety and/or depression
 Other mental health concern:
 Receiving other services
 Others:
Recommendation
 Liaise with school on the following concern:
 Learning issues for educational support
 Social / family / suspected abuse / finance issues for social welfare services
 Suspected mental health issues for C&A psychiatric services
 Others:
 Discuss in SMHSS case conference
Remark:
 Require Clinical Psychologist’s Consultation
E. Clinical Psychologist’s Consultation
Date of Consultation: / /
Clinical Psychologist’s Recommendation:
 P a g e | 89

Time spent on completing this assessment form (Sections A to E):

Prepared by Endorsed by
Signature： Signature：
Name： Name：
Post︰ ASWO Post︰ CP
Date： / / Date：

F. Group/Day Program Intervention (for group/day program participants only)

Session 1 Date: / /  Attended  Absent
Grooming:  1.Well-groomed  2. Unkempt  3. Exaggerated
Mood:  1. Anxious  2. Depressed  3. Neutral Mood
Behaviour Eye-contact:  1. Sustain  2. Brief  3. Fleeting  4. Poor  5.Avoid
Observation Verbal Expression:  1. Spontaneous  2. Fair  3. Lack reciprocity  4. Weak  5. Mute
Participation:  1. Active  2. Passive  3. Distractible
Remark:
Session 2 Date: / /  Attended  Absent
Grooming:  1.Well-groomed  2. Unkempt  3. Exaggerated
Mood:  1. Anxious  2. Depressed  3. Neutral Mood
Behaviour Eye-contact:  1. Sustain  2. Brief  3. Fleeting  4. Poor  5.Avoid
Observation Verbal Expression:  1. Spontaneous  2. Fair  3. Lack reciprocity  4. Weak  5. Mute
Participation:  1. Active  2. Passive  3. Distractible
Remark:
Session 3 Date: / /  Attended  Absent
Grooming:  1.Well-groomed  2. Unkempt  3. Exaggerated
Mood:  1. Anxious  2. Depressed  3. Neutral Mood
Behaviour Eye-contact:  1. Sustain  2. Brief  3. Fleeting  4. Poor  5.Avoid
Observation Verbal Expression:  1. Spontaneous  2. Fair  3. Lack reciprocity  4. Weak  5. Mute
Participation:  1. Active  2. Passive  3. Distractible
Remark:
Session 4 Date: / /  Attended  Absent
Grooming:  1.Well-groomed  2. Unkempt  3. Exaggerated
Mood:  1. Anxious  2. Depressed  3. Neutral Mood
Behaviour Eye-contact:  1. Sustain  2. Brief  3. Fleeting  4. Poor  5.Avoid
Observation Verbal Expression:  1. Spontaneous  2. Fair  3. Lack reciprocity  4. Weak  5. Mute
Participation:  1. Active  2. Passive  3. Distractible
Remark:
Session 5 Date: / /  Attended  Absent
Grooming:  1.Well-groomed  2. Unkempt  3. Exaggerated
Mood:  1. Anxious  2. Depressed  3. Neutral Mood
Behaviour Eye-contact:  1. Sustain  2. Brief  3. Fleeting  4. Poor  5.Avoid
Observation Verbal Expression:  1. Spontaneous  2. Fair  3. Lack reciprocity  4. Weak  5. Mute
Participation:  1. Active  2. Passive  3. Distractible
Remark:
Session 6 Date: / /  Attended  Absent
Grooming:  1.Well-groomed  2. Unkempt  3. Exaggerated
Mood:  1. Anxious  2. Depressed  3. Neutral Mood
Behaviour Eye-contact:  1. Sustain  2. Brief  3. Fleeting  4. Poor  5.Avoid
Observation Verbal Expression:  1. Spontaneous  2. Fair  3. Lack reciprocity  4. Weak  5. Mute
Participation:  1. Active  2. Passive  3. Distractible
Remark:
 P a g e | 90

G. Remark

Time spent on completing this assessment form (Sections F to G):

Prepared by
Signature :
Name :
Post : ASWO
Date : / /
 P a g e | 91

Appendix 15: Assessment form – HA assistant social work officer (Individual

Interview) (for cases identified with subclincial anxiety and depressive mood
symptoms only and unknown to HA C&A psychiatric services)

Hospital Authority
Student Mental Health Support Scheme
Individual Case Assessment Form
Cluster: Name: ( ) Sex/Age: M / F ( )
 HKWC  KEC  KWC School: Class:
 NTEC  NTWC Case no.: HKID/BC* no. : ( )

 Via school based annual screening exercise

Referral Source:
 “Unknown” cases with subclinical anxiety and/or depressive mood symptoms from SMHSS
Referral Reason:  Anxiety  Depressive Mood  Anxiety and Depressive Mood  Others :
Date of Referral: Intake Date:
Interviewee:  Student  Mother  Father  Carer :  Others:
A. Pre-Treatment Assessments (Date:_____________________)
Total
1.  SCAS (Parent) Total Score: 6.  MFQ
Score:
Total
2.  SCAS (Child ) Total Score: 7.  PHQ9
Score:
Total
3.  CBCL (Parent) Total Score: 8.  GAD7
Score:
Total
4.  YSR (Self) Total Score: 9.  PSS10
Score:
Total
5.  TRF (Teacher) Total Score: 10.  Others:
Score:
B. Family
1. Family History of Psychiatric Concern (  N/A)
 Father  Mother  Others:
Remark:
2. Parent/Child Relationship
Relationship with:  Father  Good  Satisfactory  Fair  Poor  N/A
Mother  Good  Satisfactory  Fair  Poor  N/A
Carer  Good  Satisfactory  Fair  Poor  N/A
Remark:
3. Parenting
 Authoritarian  Minimal involvement
 Permissive  Authoritative
Remark:
4. Parents' Marital Relationship)
 Good  Satisfactory  Fair  Poor  N/A
Remark:
5. Sibling Relationship
 Good  Satisfactory  Fair  Poor  N/A
Remark:
C. Developmental History
 Appropriate Development
 Developmental Delay:
 Temperament:  Easy  Difficult  Slow to warm up  Others:
Remark:
 P a g e | 92

D. School
1. School Attendance  Stable  Unstable  Non-attendance  N/A
Remark:
2. Academic Performance  Good  Above average  Average  Below average  Poor  N/A
Remark:
3. Adjustment to School  Good  Satisfactory  Fair  Poor  N/A
Remark:
4. Relationship with Schoolmates/Peers  Good  Satisfactory  Fair  Poor  N/A
Remark:
5. Relationship with Teachers  Good  Satisfactory  Fair  Poor  N/A
Remark:

E. Case Conceptualization
Presenting Problems

Predisposing Factors

Precipitating Factors

Perpetuating Factors
 P a g e | 93

Protective Factors

Supplementary Information

F. Recommendations on Service Pathway

 Target case Reason:  Subclinical Anxiety  Subclinical Depressive Mood  Others:
 Accept SMHSS ASWO’s individual case service (Next FU date / time : at hours)
 Decline service
 Discuss in SMHSS case conference
 Others:
__________
Remark:
 Non-target case Reason:  No mood concern
 Student's symptoms subsided
 Suspected clinical anxiety and/or depression
 Other mental health concern:
 Receiving other services
 Others:
Recommendation for Non-Target Case
 Liaise with school on the following concern:
 Learning issues for educational support
 Social / family / suspected abuse / finance issues for social welfare services
 Suspected mental health issues for C&A psychiatric services
 Others:
 Discuss in SMHSS case conference
Remark:
G. Care Plan
Problems to be tackled
 P a g e | 94

Objectives

H. Clinical Supervisor’s Comments

I. Remarks

Time spent on completing this assessment form:

Prepared by Endorsed By
Signature ： Signature ：
Name ： Name ：
Post ： ASWO Post ： CP
Date ： Date ：
 P a g e | 95

Appendix 16: Parent’s Notice (家長通知書)

敬啟者︰

「醫教社同心協作計劃」 - 年度問卷篩查
家長通知書

食物及衞生局聯同醫院管理局、教育局和社會福利署由 2016/17 學年起，推出「醫教社同心

協作計劃」(「計劃」)。其中，醫院管理局的專責社工將與學校合作進行年度問卷篩查，旨在及
早識別並協助受焦慮、抑鬱情緒困擾的兒童及青少年，為他們提供適切的支援服務，包括教育講
座、小組活動、評估工作及個案諮詢等，以促進學生的個人成長及心靈健康。

根據外國的經驗，大部份受焦慮情緒困擾的學生，若能及早接受適當的介入服務，焦慮的情
緒會有所舒緩。除此之外，學生的同儕、親子、師生關係及學業成績各方面也許會有所改善。現
時，很多先進國家也開始進行以學校為本的學生焦慮及早識別和介入服務。

本年年度問卷篩查有關安排詳情如下︰

第一階段：由* 家長 / 學生 填寫問卷，初步了解學生的情緒狀況
第二階段：根據問卷調查的結果，醫院管理局的專責社工會透過校方與懷疑受焦慮情緒
困擾的學生及家長聯絡，作進一步的跟進
第三階段：為合適的學生提供適切的服務，例如「焦慮情緒管理小組」或個別跟進服務

本計劃專責社工將於_____年___月___日發放有關問卷予 * 貴家長 / 子女 填寫，問卷內容

只會用於評估、研究及教育之用，有關個人資料將會保密。如有需要，我們會進一步邀請* 貴家
長 / 子女填寫相關問卷作資料補充，以便提供更適切的服務。

如你有任何疑問，或希望根據《個人資料 (私隱) 條例》要求查閱 / 改正本計劃持有你的個

人資料，請透過學校 XXX 與我們聯絡，或致電 2959 8094 與本計劃專責社工 XXX 姑娘聯絡。

此致

XXX

二零 XX 年 X 月 XX 日
 P a g e | 96

Appendix 17: Parent’s guideline on completing questionnaire (家長填寫問卷

指引)

家長填寫問卷指引

請家長依以下指引填寫問卷︰

1. 請家長依問卷的指示作答所有題目，並用原子筆填滿答案之
圓圈，例如「」。

2. 問卷之答案沒有對錯之分，請家長按個人實況填寫。

3. 為保持問卷的完整性，請勿對摺、摺曲或釘裝問卷。

4. 問卷完成後，請妥善保存及由子女轉交學校老師，再作跟
進。

~多謝合作 ~
 P a g e | 97

Appendix 18: Acknowledgement Receipt of Data

年度問卷篩查 - 問卷數量核對回條
(請於交問卷當日交回)

本學校現確認收回問卷共_________________份 (年級______________)，並於_________年_______月

______日由學校同工交回醫院管理局相關辦事處 (地址：葵涌醫院道 3-15 號葵涌醫院 J 座 1 樓)。

學校蓋印: 學 校 負 責 同 工 簽 署：

學 校 負 責 同 工 姓 名：

學 校 名 稱：

聯 絡 電 話：

日 期 ：

(For office use only)

年度問卷篩查 - 問卷數量核對回條

醫院管理局現確認收到學校交回問巻共______________份 (年級______________)。請學校員工及醫院管理

局負責員工即場點算問卷數量作實，如問卷數量與學校填寫數量不符，請學校自行負責。

學 校 員 工 簽 署：

學 校 員 工 姓 名：

醫 院 管 理 局 員 工 簽 署：

醫 院 管 理 局 員 工 姓 名：

日 期 ：

備註︰核對回條醫院管理局影印存檔
 P a g e | 98

VI. References

1. Mental Health Review Report, April 2017

2. Service Enhancement for Student with Mental Health Needs: A School-based Multi-disciplinary
Collaboration Platform for Students with mental Health Needs ( MSDC P444)
3. Mental Health Policy and Service Guidance Package: Child and Adolescent Mental Health Policies
and Plans, World Health Organization, 2005
4. REACH chronicle: a communicty mental health model for children and adolescents in Singapore D.
Fung et al.