Referral and Assessment Form

                                                               

1) Client Information                                                      Date:                                                                   

 

Name:                                                                                                 Other Names Used:                           

 

DOB:                                                        Age:           Personal Health Number:                             

                    (year)                   (month)       (day)

 

Contact Number:                                                                                  Message OK?   Yes    No

                                                                       

Gender:                             Marital Status:  S   M   D   W         Children:             In care?  Yes No

 

Ethnicity/Cultural Identification:

¨Aboriginal     ¨Afro-Canadian     ¨Asian     ¨Indo-Canadian     ¨Latin      ¨Caucasian   

¨Other:                         Hair colour:               Eyes:              Weight:                Height:                  

Identifying marks (tattoos, piercing, birth marks etc.):                                                                      

 

Current Address:                                                                                  Postal Code:                           

 

 


2) Parent/Guardian/Emergency Contact Information

Emergency Contact:                                                                Tel.#:                                                 

 

Parent(s) Name:                                                                      Tel.#:                                                 

 

Are you in Care?                      Yes      No       if yes, for how long?                                                   

 

Social Worker:                                                                         Tel. #:                                                            

Office Location:                                                                                                                                 

Caregiver/Foster Parent:                                                          Tel.#:                                                            

 


3) Treatment History

Have you participated in treatment/counseling for alcohol and drug related issues before?   Yes    No if yes, please detail (when/where):                                                                                                                                                                                                                                                                                                                                                    

Have you worked with Watari services before?   Yes    No  if yes, when/how                                                                      

 


4) Medical Information (Physical / Emotional Health)

Are you currently affected by or have you ever experienced any of the following:

▢        Allergies:                                                                                                                                        serious?  Y  /   N

please specify

▢        Asthma/hay fever                                                                                         ▢   Skin Condition

▢        Sleep Disturbances (incl. nightmares)                                                     ▢   Heart Trouble

▢        Head injury / concussion                                                                           ▢   Travel / motion sickness

▢        Fainting / Dizzy spells                                                                                ▢   Stomach / bowel trouble

▢        Convulsions / Seizures                                                                               ▢   Kidney/bladder infections

▢        Frequent Headaches                                                                                    ▢   Diabetes

▢        Nose / Throat infections                                                                            ▢   Broken Bones (specify)                              

▢        Ear Infections/ Hard of hearing                                                               ▢   Liver Problems / hepatitis

▢        Chronic Cough                                                                                             ▢   Anorexia / Bulimia

▢        Lung disease                                                                                                  ▢   Depression

▢        Other                                                                                                               ▢   Anxiety          

                                                               

Details:                                                                                                                                                                                                                                                                                                                                                                                                                 

 

Are you currently taking any medications?                        Yes         No          if  yes, Name & Purpose                                                                                                                                                                                                                                                                                                                                                                                                                                                   

 

Have you been diagnosed with a mental health issue/illness?                      Yes        No   if yes, what, & treatment received                                                                                                                                                                                                                                                                                                                                                                                                                     

 

Have you ever attempted suicide?       Yes         No         if yes, please indicate when, and whether you received support                                                                                                                                                                                                                                                                                                                                                                                                

 

Have you ever self-harmed?      Yes         No          if yes, please indicate nature of & when you last hurt yourself:                                                                                                                                                                                                

 

Are you pregnant?          Yes         No          Maybe    if yes, # of weeks?                                                                              

 

Do you have a history of violent behaviour?     Yes         No          if yes, please describe:                                                                                                                                                                                                                                                       

 

 


5) Substance Use/Misuse Information

 

Substance Used

Age of first use

Date of last use

Pattern of use: (route of admin, amount used, #times per day)

Alcohol

 

 

 

Marijuana

 

 

 

Cocaine

 

 

 

Crack

 

 

 

Heroin

 

 

 

Crystal Meth

 

 

 

Lsd

 

 

 

Mushroms

 

 

 

Ecstasy

 

 

 

Inhalants

 

 

 

PCP

 

 

 

Prescription Drugs (specify)

 

 

 

Methadone

 

 

 

Other

 

 

 

 

 

 

 

 

Are you currently on a methadone program?   Yes      No       if yes, Current Dosage:            Mg

Date Started:               Prescribing Doctor:                                          Tel. #:                                   

 

 

Readiness to Change:     Which one of the following statements most nearly represents where you are      at in relation your drug/alcohol use?

 

1.  Drugs/alcohol aren’t a problem for me. I have no intention of changing.                (pre-contemplation)

 

2.  I’m starting to think drugs/alcohol might be a problem,  I am trying to

understand the effects they have in my life and I think about changing.                  (contemplation)

 

3.   Drugs/alcohol have brought problems into my life. I need to do something

and would like some support and ideas on how to make changes.                                    (prep./decision       

                                                                                                                                           making)

 

4.  I have taken some steps to change my drug/alcohol use and want to keep

     working on this. I am putting my plans into action.                                                             (action)

 

5.  While it’s hard, I have been substance free/use at my goal level for 6 months.

     I am continuing to change and would like continued support.                               (maintenance) 

    

 


6) Legal Involvement

Do you have any past or current legal system involvement?                Yes      No

if yes, please list charges:                                                                                                                                                                                                                                                                               

Current situation:                                                                                                                               

Probation / Parole Officer’s Name:                                                                Phone:                        

 


7) Employment / Education History

Are you currently in school?    Yes /  No   if yes, Name of School:                                                   

Grade:                 if no, last grade completed:                        

Have you ever been employed?    Yes      No              Currently?        Yes      No

if yes, please outline your employment history:                                                                                                                                                                                                                                              

 


8) Friends / Family Relationships

Approximately how many good friends do you have?                                                                                    

How many friends do you have who are either not misusing substances or who are trying to make changes in their lives?                                       

Who would most support you in coming to treatment?                                                                      

Briefly describe your family and/or home situation:                                                                                                                                                                                                                                      

                                                                                                                                                           

 


9) Current Context

What makes you come for counselling now?                                                                                                                                                                                                                                                  

Out of 100%, how much of your decision to come to this program is your own?                             %

and how much are you here because someone else wants you to be                                                %

What could help you to be here more for your own reasons?                                                             

Are there any other issues you feel you need to deal with? (please check off any that apply)

¨self-esteem  ¨anger management  ¨grief /loss   ¨social skills   ¨unhealthy/dangerous relationships   ¨parenting skills   ¨history of abuse   Other:                                                                  

Are there any topics that might be hard for you to talk about or that might trigger you?                                                                                                                                                                              

 

Getting to Know You…

List three things you like to do                                                                                                          

Three things you would like to try                                                                                                     

One thing that you do well                                                                                                                

What are three words a friend would use to describe you?                                                                 

List three words you would use to describe yourself                                                                          

Is there anything else that you think is important for us to know about you?                                                                                                                                                                                                            

 


10) Community Contacts

Please list all the professionals/support people that you are connected with or have worked with recently:

                               

Parent(s):                                                                                                              Tel. #:                                                                   

 

Alcohol & Drug Counsellor:                                                                            Tel. #:                                                                   

 

Social Worker:                                                                                                     Tel. #:                                                                  

 

Counsellor:                                                                                                            Tel. #:                                                                  

 

Outreach Worker:                                                                                                Tel. #:                                                                  

 

Doctor:                                                                                                                   Tel. #:                                                                  

 

Mental Health Worker:                                                                                      Tel. #:                                                                  

 

Probation / Parole Officer:                                                                               Tel. #:                                                                  

Other:                                                                                                                     Tel. #:                                                                  

Other:                                                                                                                     Tel. #:                                                                  

 


11) Client Signature

I state that the information in this referral / application is true to the best of my knowledge and that I am applying to participate in the Watari Youth Day Treatment Program willingly.

 

 

 

                                                                                                                                                                                                               

                                                Client signature                                                                                                         Date

Would you be open to being contacted to answer a few questions about your experience of the program within the year following your participation in the program?          Yes         No

12) Referral Source

 

How did you hear about the Day Program?                                                                                       

Are you being referred to the program?  If so, who is referring you?                                                  

 

If referred by a professional (ex. counsellor, outreach worker, probation officer etc.) Please ask them to fill out the following questions and return with your referral form.

 

A) Is this young person receiving counselling from you?                                Yes      No

If yes, how often and for how long?                                                                                                   

If no, in what capacity are you working with this youth?                                                                   

Will you continue to see this young person during and after treatment?         Yes      No

 

B) What do you see as this youth’s particular strengths and abilities?

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   

 

C)  What is your perception of this youth’s readiness for change?  In your opinion, what are some potential challenges she/he may face?                                                                                                                                                                                                                                                                                                                                                                                                                    

 

D)  What do you see as the overall treatment goals for this youth?                                                                                                                                                                                                                                                                                                                                                                            

 

E) What is the aftercare plan for this youth following Watari?                                                                                                                                                                                                                                                                                                                                                                                               

How can Watari support this plan?                                                                                                                                                                                                                                                                

 

F) Please add any additional information that might assist Watari staff in supporting this youth.                                                                                                                                                                 

Please attach any mental health/treatment assessments pertaining to this youth.*