SMART Wokingham Young persons Screening and Referral Form Referral Source Date: Name of worker: Contact number: Referring Agency: Email address: Client Information Surname First Name Title Previous Name Preferred Name M/F Date of Birth Age Religion Ethnicity Telephone number Mobile Number Address (include full postcode) Parents/carers name Relationship Contact number: GP details (name, address) Ethnicity codes White A British B Irish C Other White British Mixed D White & Black Caribbean E White & Black African F White & Asian G Other Mixed Asian / Asian British H Indian J Pakistani K Bangladeshi L Other Asian Black / Black British M Caribbean N African O Other Black Other Ethnic R Chinese S Any other Z Not stated School/further Y N Young person s availability for appointments education Pupil/student Receiving benefits Employed Unemployed Parental status Y N Child Care responsibilities, if so details of children Parent Not a parent Expectant Pregnant Current Children s Social Care involvement Brief details of involvement
Accommodation status Living in own accommodation NFA Living with friends/family Sofa surfing Other (please specify) Any other current accommodation issues? (please specify) Learning Disability? Yes No Dual Diagnosis? Yes No Allocated CAMHS worker? Substance use and related issues What is the defined problem (in their words) Prompts: illicit or prescription drugs with or without alcohol? Class A or other? Problems caused? Do you want to be treated? Referrer s Expectations Professional involvement - Is client involved in any current professional involvement, if so who and what work is being delivered
Drug use assessment Current drug use: Have you used any of the following in the last 30 days (or prior to remand)? Recent use Drug Frequency Amount per day Heroin Other opiates Cocaine / crack Amphetamine Ecstasy Cannabis Hallucinogens* Benzodiazepine* Alcohol Prescribed medication + OTC Tobacco Other * Please specify prescribed or not Level of family support, are family getting any support Cost Route Date of last use First use Date first used Age Offending behaviour Brief summary of criminal justice involvement if applicable Is substance misuse linked to offending Priority checklist Client is currently injecting drugs Client has physical health conditions/symptoms that are likely to require treatment Client has psychiatric problems that are likely to require treatment Children may be at risk There is concern about the client s risk of self-harm There is concern that the client may represent a safety threat to others There is concern about the offending behaviour Homelessness/no fixed abode
CONSENT (Explicit) The National Drug Treatment Monitoring System (NDTMS) system involves collecting information about the type of treatment you receive from a treatment agency. Your full name and address are not passed on to the NDTMS it is details such as your initials, date of birth, gender, postcode (partial unless there is local consent), ethnicity and local authority of residence. There is nothing in the information that could be used to identify you. Your information is very useful for helping to plan and develop services that can best meet your needs. In order to produce information that measures this, the NTDMS data is matched with other government departments data. All data matching is undertaken by Public Health England, and at no point is you personal information shared with other government bodies. If you do not want information to be passed on to Public Health England you have the right to say this. If you wish to know more about the NDTMS (including why information is needed for the NDTMS, how the information is handled within the NTDMS and/or the type of information collected for NDTMS and the time it is retained) please ask your key worker. You have the right to apply for access to any records kept about your health. Your information will not be used for any other purpose and will not be passed to any other third party without your permission save that the Treatment Provider may share your information with the certain law enforcement agencies, other public authorities or others for the purposes of the prevention or detection of crime or where there are concerns in respect of safeguarding young people or vulnerable adults. I have been advised that I can withdraw my consent to this information being shared with NDTMS and Wokingham DAAT at anytime and that if I do not consent to my information being shared with NDTMS and Wokingham DAAT it will not prevent me getting the treatment I need. Consent (other) It is recognised that people cannot overcome issues with substances/alcohol without support. Information also needs to be shared with other professionals in order to ensure that they work collaboratively in the best interests of the individual. Supporting information should be provided as to the level of contact or support that can be expected from the identified agencies/people. Substance Misuse Consent to share information Support available and assessment to be shared with: (Lead name where relevant)
Carer/Family member/friend GP Community Mental Health Team Other drug/alcohol, service CSC YOS Accommodation Provider Jobcentre Plus SCHOOL Other (please specify) Other (please specify) Supporting information that might have a bearing on substance misuse Individual: Assessor:. Referral When completed please forward this completed form to: SMART 38 Station Road Wokingham Berkshire RG40 2AE
Telephone: 01189772022 or email at wokingham@smartcjs.org.uk (please note: this e-mail address should only be used for referrals) Fax : 01189 797731 Screening conducted by Name Agency Date Time Signature of agreement of the transfer of information I understand I will be referred on or offered a more detailed assessment and a care plan will be developed. Client name: Date Clients Signature: Parent/carers name: Date Parent/carers signature:
Risk assessment: Please tick whichever box is appropriate. If unknown? SELF HARM: Deliberate and Suicide Depressed mood (subjective) Past history of nonsuicidal self harm Plans made Actions taken on plan Expressing high levels of distress Previous suicide attempt Yes No? Yes No? Impulsivity Suicidal ideas Discovery avoided Final acts (i.e. notes, letters) Recent bereavement Details: Dangerous method (high risk to self and others i.e. irresponsibility Details: Accidental Overdose Poly drug use History of past overdoses Has witnessed overdose(s) by others Sharing equipment Regular intravenous use Injects alone Neck/Groin injecting Binge drinker Drinking until History of alcohol blackouts unconscious HARM TO OTHERS: Aggression Yes No? Yes No? Relevant criminal record Lack of provocation Thoughts/threats of violence Available weapons Past history of violence to others (may include sexual violence) Lack of regret Paranoid thoughts/delusions Target(s) identified Conflict Details: Impulsivity Preoccupation with violent fantasy