School Consultation Note (Child/Adolescent Psychiatry)

Date of Service: [Date and time or duration]

Setting: [in-person / video / phone / written consult]

Note Type: School Consultation Note (Child/Adolescent Psychiatry)

Author: [Name, credentials]

Reason for Consult

Requesting Party: [Name, role, organization]

• Consult Questions:
  • [Question 1 phrased as an answerable prompt]
  • [Question 2]
  • [Additional questions as applicable]
• Urgency: [routine / urgent] (If urgent, include rationale.)

Participants & Information Sharing

• Participants: [Student: present / absent], [Parent/guardian(s): names], [School staff: names and roles], [Outside clinicians: names and roles]
• Information Sources: [meeting / collateral calls / record review / combination]
• Consent Status: [Parent/guardian consent: obtained / not obtained], [Youth assent: obtained / not obtained / not applicable], [Scope of sharing: what may be shared and with whom]
• Release of Information: [on file / not on file] (If no ROI: "Recommendations below are for family use only.")

Sources of Information

• Informants: [Student interview], [Parent/guardian], [School staff by name and role], [Other clinicians]
• Documents Reviewed: [Document type and date] (Include IEP/504 plan, psychoeducational evaluations, FBA/BIP, discipline history, attendance reports, grades, safety plans, psychiatric records as applicable.)
• Data Limitations: [Missing inputs and impact on recommendations] (e.g., "Teacher input not available.")

Summary

(Keep concise and scannable for school team use.)

• Student Context: [Age], [Grade], [School type], [General education / special education], [Brief presenting theme]
• Current Concerns:
  • [Concern with attribution: student / parent / school / records]
  • [Additional concerns with attribution]
• Risk Status: [low / moderate / high], [acute / chronic] (Include basis for level. Omit if safety not relevant to consult.)
• Top Recommendations:
  • [Priority 1: safety-related if applicable]
  • [Priority 2: learning access]
  • [Priority 3: behavior/regulation support]
  • [Additional recommendations as needed, 3-5 total]

Educational Context

• Placement: [Grade], [Classroom type], [IEP / 504 / none] (If IEP: [Eligibility category], [Key services and accommodations].)
• Academic Functioning: [Strengths], [Areas of difficulty], [Work completion patterns], [Supports tried and response]
• Behavior and Regulation:
  • Target Behaviors: [Operational definition: what, frequency, intensity, duration]
  • Antecedents/Triggers: [Task demands / transitions / peer conflict / sensory factors / unstructured time / other]
  • Effective Strategies: [De-escalation or supports that have worked]
  • Ineffective Strategies: [Approaches tried without success]
• Social Functioning: [Peer relationships], [Bullying concerns], [Trusted adults at school]
• Attendance Pattern: [Full absences / tardies / early dismissals / class avoidance], [Reported drivers], [Prior interventions and response] (Include when relevant to consult question.)

Presenting Problem

[Chief concern] (If student not interviewed, label this section "Collateral History" and specify sources.)

• Chronology: [Onset], [Course], [Key change points including school transitions, incidents, stressors]
• Current Severity and Impact: [Instructional time lost], [Suspensions/discipline], [Nurse visits], [Other functional metrics]
• Contextual Triggers: [Situations, settings, or tasks associated with difficulties]
• Interventions and Response: [What has been tried], [Response], [Barriers]
• Student Perspective: [Brief student quote clarifying their experience] (Include when interviewed and helpful.)

Clinical Background

(Include only history that informs school supports.)

• Working Diagnoses: [DSM/ICD diagnoses; label provisional or rule-out as appropriate]
• Current Medications: [Medication, dose, timing] with school-relevant effects [sedation / appetite / irritability / attention]
• Neurodevelopmental Considerations: [ADHD], [Autism], [Learning profile], [Sensory concerns] (as applicable)
• Medical Factors Affecting School: [Sleep], [Migraines], [Chronic pain], [Somatic symptoms]
• Family/Psychosocial Context: [Factors affecting attendance or school communication] (Minimize sensitive details not needed for school problem-solving.)

Mental Status Exam

(If collateral-only or limited contact, state "Not performed—collateral consult" or describe limitation.)

• Appearance: [Observations]
• Behavior: [Activity level, cooperation, motor behavior]
• Speech: [Rate, volume, articulation]
• Mood/Affect: [Stated mood], [Observed affect: quality, range, reactivity]
• Thought Process/Content: [Organization], [Preoccupations or concerning content if present]
• Cognition/Attention: [Orientation, attention, concentration as observed]
• Insight/Judgment: [Observations]
• Impulse Control: [Observed and reported]

Objective Data

(Include when available; omit section if none obtained.)

• Rating Scales: [Scale name], [Reporter], [Date], [Score], [Interpretation]
• School Data: [Attendance percentage and timeframe], [Office discipline referrals], [Grades/progress]
• Psychoeducational Testing: [Date], [Evaluator], [Key findings relevant to instruction or behavior]

Risk Assessment

(Include when safety is part of the consult question or any concern exists. If not assessed, state "Not assessed" with rationale.)

• Risk Types Assessed: [suicidal ideation/behavior / self-injury / aggression / elopement / abuse-neglect]
• Key Findings: [Presence/absence of ideation], [Plan or intent], [History of attempts or self-harm], [Access to means], [Acute triggers], [Protective factors]
• Risk Level: [low / moderate / high], [acute / chronic] with rationale
• Safety Plan and School Mitigation: [Who student reports to], [Crisis escalation pathway], [Supervision needs], [Reassessment triggers], [Parent notification plan]

Assessment

• Diagnostic Impression: [DSM/ICD diagnoses with specifiers; label provisional or rule-out clearly]
• Formulation:
  • Problem: [Primary problem]
    • Predisposing: [Vulnerabilities and history]
    • Precipitating: [Recent triggers]
    • Perpetuating: [Maintaining factors such as escape reinforcement, inconsistent responses]
    • Protective: [Strengths and supports]
  • (Repeat for additional problems as needed.)
• Diagnostic Uncertainty: [Areas of uncertainty and how they affect school recommendations] (Include when applicable.)

Recommendations

(Tie each recommendation to a functional impairment or safety need. Use "recommend the school team consider" rather than making eligibility determinations.)

• Immediate (0–72 hours):
  • [Safety procedures and crisis response if applicable]
  • [Supervision needs and escalation pathway]
  • [High-urgency accommodations]
  • [Communication plan: point of contact on each side, mode, frequency]
• Short-term (1–4 weeks):
  • [Attendance/avoidance plan: hypothesized function, graduated re-entry steps, progression criteria, targets]
  • [Classroom accommodations: symptom → limitation → accommodation]
  • [Behavior support: FBA consideration, function-based intervention, replacement skills, data collection approach]
  • [School mental health supports: counseling, check-ins, coordination with outpatient providers]
  • [Academic evaluation: consider psychoeducational testing if ability-performance mismatch]
  • [What to avoid: e.g., punitive-only responses to anxiety-driven avoidance]
• Longer-term (1–3 months):
  • [Review efficacy with data; refine supports as needed]
  • [Generalization plan for effective strategies]
  • [Transition planning for class changes or grade advancement]
  • [Ongoing communication: frequency, mode, data to track]

Follow-Up

• Communications Completed: [Who], [Method], [Summary]
• Documents Provided: [Forms, letters, or other materials]
• Next Clinical Follow-Up: [Date and modality]
• Records Requested: [Document type and source]
• Contingency Instructions: [What to do if worsening occurs before next contact]
• Total Clinician Time: [Minutes] (Include when required for billing.)

(Use neutral, behaviorally specific language throughout. Maintain clear attribution for all information. Label clinical inferences explicitly. When a standard domain was not assessed, include header with "Not assessed" rather than omitting. Assume note may be shared with school.)