Professional Documents
Culture Documents
Operations Guideline - Student Mental Health Support Scheme (Version 2.0) (Final) PDF
Operations Guideline - Student Mental Health Support Scheme (Version 2.0) (Final) PDF
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
A. Medical ................................................................................................................................................ 26
B. Education ............................................................................................................................................. 29
C. Social .................................................................................................................................................... 30
6. Documentation ............................................................................................................................................ 32
8. Evaluation ................................................................................................................................................... 37
V. Appendices .................................................................................................................................................................. 39
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 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
Pa ge |3
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
Summary of Changes
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.
Pa ge |8
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.
Pa ge |9
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
P a g e | 10
9. The operation definition and the multi-sectoral involvement in the Three-Tier Stepped Care Model
are described in the Appendices. (Appendices 1, 2)
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
Target Students
P a g e | 12
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.
(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.
P a g e | 13
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
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:
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.
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).
P a g e | 16
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)
P a g e | 17
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.
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
P a g e | 18
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).
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.
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.
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.
P a g e | 20
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)
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)
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
Figure III.2
Students requiring
further follow up after
Standard brief assessment by designated psychiatric nurses
annual screening (Appendix 12)
exercise and/or (e.g. on behavioral/eating problems, clinical anxiety or
depression)
intervention by ASWOs [+/- standard assessment tools (e.g. PHQ-9(Appendix 12A), GAD-
7(Appendix 12B)) (for secondary school students only)]
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
Students/Parents/Legal
Guardians do not give
consent for the screening
Students require
Intervention by ASWO* (group/ individual)
further follow-up
Students’ problem
settled
A. Medical
51. The designated psychiatric nurse, with support from multi-disciplinary healthcare team in HA, is
responsible for -
Roles Responsibilities
1. Steering the multi-disciplinary Co-chairing the school-based multi-disciplinary
team via a school platform for platform
early identification of target Liaising with other multi-disciplinary team members to
students and determination of identify target students for further support and
suitable services and appropriate determine suitable services and appropriate level of
level of support for referred cases support for referred cases
52. The CP, with support from multi-disciplinary healthcare team in HA, is responsible for:
Roles Responsibilities
1. Providing mental health and Conducting assessment to identify psychological,
psychological assessment, emotional and/or behavioral issues and providing
consultation and psychological suitable consultation and intervention for cases referred
intervention for referred cases via the school platform in formulation and
implementation of the care and support
3. Overseeing the enhanced services Providing appropriate supervision to the ASWO and
delivered by the ASWO 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
4. Providing expert advice to other Providing expert advice from the clinical psychology
multi-disciplinary members perspective to other multi-disciplinary members to
facilitate students’ psychological functioning
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
B. Education
School personnel
3. Formulating the care plan from Based on the care plan, work in collaboration with
educational perspective 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.)
4. Coordinating with relevant school Liaising with relevant school personnel, including
personnel to work closely with the class/subject teachers and student guidance
multi-disciplinary team to implement personnel to follow up the implementation of the
the care plan care plan in different school contexts
5. Monitoring the implementation of the Working with the school personnel to review and
care plan for respective students and adjust the implementation of accommodations if
adjusting the plan to suit their needs if needed
necessary 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
C. Social
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)
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
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.
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
Areas to be covered
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
Evidence-based treatment programmes available at school which support students with specific
mental health problems
64. The main focus of the training course for general school personnel is on
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
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
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
CD Conduct Disorder
EP Educational Psychologist
HA Hospital Authority
V. Appendices
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.
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
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 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
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 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
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.
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
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。
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:-
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))^
P a g e | 49
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
Diagnosis: __________________________________
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
P a g e | 51
4. Social Skills
Eye-contact: Sustain Brief Fleeting Poor Avoid
5. Mental State
5.1 General Condition:
(Please specify: )
(Please specify: )
(Please specify: )
(Please specify: )
(Please specify: )
(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)
(Please specify: )
(Please specify: )
( Signature )
P a g e | 54
_____/_____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:
____________________________________________________________________________________________________
#
(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):
__________________________________________________________________________________________________
P a g e | 55
(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]:
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
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
P a g e | 59
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
P a g e | 60
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)
備註
完成評估所需時間:______________________________________________________
P a g e | 61
Reference No.:
Name of the Student:
Sex / Age:
School:
Class Level:
Known Case of School Social Worker: No Yes, since: ___________________
If yes, please specify:
Source of Referral:
School Principal/ Vice-Principal Educational Psychologist Other welfare agency
Discipline Teacher Student Guidance Officer Self-referral
Guidance Teacher Schoolmate Identified by school social worker
Teacher Client’s parent/ family members Others_______
Reason(s) for Referral:
Genogram:
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
P a g e | 62
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:__________________________
P a g e | 63
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
P a g e | 64
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:__________________________
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)
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)
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
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
2. To monitor and tackle her emotional swing pre and post examination
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
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
6. School social worker will liaise with the MSW( who follows her mother School social worker
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
Etc….
* 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
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
performance
EP
4 Teachers may arrange extra tutorial sessions Teachers
needs.
5 School social worker will arrange interviews School social
MSW( who follows her mother mental worker
8 Refer Clinical Psychologist for further Designated
Progress:
P a g e | 70
Serial No :
Date : / /
Integrated Assessment and Care Plan
(For Students known to HA C&A Psychiatric Services)
Problems
Predisposing 1.
Factors *
Precipitating 1.
Factors *
Factors * 1.
Protective Factors 1.
*
Objectives 1.
P a g e | 71
multi-disciplinary Interventions By
2.
3.
4.
5.
6.
7.
8.
Target timeline 1.
P a g e | 72
4.
Progress:
* 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
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
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
2. To monitor and tackle her emotional swing pre and post examination
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
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
6. School social worker will liaise with the MSW (who follows her mother School social worker
health condition.
7. School social worker will convey the message “advance the follow up School social worker
arrange appropriate intervention to the student and will also advise him
reference for the case conference and the care plan formulation.
Etc….
4.
Progress:
P a g e | 76
Serial No :
Integrated Assessment and Care Plan Date : / /
Predisposing 1.
Factors *
Precipitating 1.
Factors *
Factors * 1.
Protective Factors * 1.
Objectives 1.
P a g e | 77
multi-disciplinary
approach Interventions By
2.
3.
4.
5.
6.
7.
8.
4.
Progress:
* 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
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
Name: _____________________ ( )
Student Mental Health Support Scheme
HKID: __________________ Sex/Age: _____________
Standard Brief Assessment Form DOB: _________________Case no.________________
1. Genogram:
2. General Health
3. Behaviour
Strengths / Hobby: __
Academic Performance: Good Above Average Average Below Average Poor N/A
________________________________________________________________)
4. Emotion / Cognition
Mood: Euthymic Anxious Depressive Elated Irritable Others (____________________)
Others (_______________________________________________________________________)
(*Delete as appropriate)
5. Inter-personal / Social Relationship
Relationship with: - *Father/Carer ( ) Good Satisfactory Fair Poor N/A
6. Risk Level
Suicidal Ideation: Denied Fleeting Vague Concrete
Warning Signs of Suicidal Intention: N.A.D. threatening to kill own self Suicidal Notes
________________________________________________________________)
________________________________________________________)
7. Any medical / psychiatric / psychological / social support service received (If applicable):
* Please supplement if any reports are available. *
_______________________________________________________________________________
_______________________________________________________________________________
________________________________
_______________________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
11. [For Secondary school students only] GAD 7 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)
________________________________________________________________________________
Time spent on completing this integrated assessment and care plan:
「醫教社同心協作計劃」
焦慮自我評估量表 (GAD-7)
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
Prepared by Endorsed by
Signature: Signature:
Name: Name:
Post︰ ASWO Post︰ CP
Date: / / Date:
G. Remark
Prepared by
Signature :
Name :
Post : ASWO
Date : / /
P a g e | 91
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. : ( )
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
Objectives
I. Remarks
Prepared by Endorsed By
Signature : Signature :
Name : Name :
Post : ASWO Post : CP
Date : Date :
P a g e | 95
敬啟者︰
「醫教社同心協作計劃」 - 年度問卷篩查
家長通知書
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
此致
XXX
二零 XX 年 X 月 XX 日
P a g e | 96
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
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
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 :
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