REFERRAL SOURCE GUIDELINES. Listed below is a general outline of the referral, interview and intake process at Last Door Recovery Centre.

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Transcription:

REFERRAL SOURCE GUIDELINES Listed below is a general outline of the referral, interview and intake process at Last Door Recovery Centre. 1. Contact Last Door Recovery Centre at 1 888 525 9771 to determine bed availability and funding requirements. 2. Please complete and fax the Referral Package, provide funding confirmation and any other requested reports (these may be faxed separately) to 604 525 3896 3. Arrange for the client to attend a program viewing and/or screening interview. If your client is attending a screening interview and an intake is advised, program participation commences immediately following program acceptance. 4. Upon intake Clients are assigned a case manager who will be the primary care contact for referral sources and family. 5. The program length is recommended a minimum of ninety days. The length of stay is determined by individual needs and abilities. Additional program participation will be reviewed with the client and his support team. 6. Visits with clients must be prearranged and are limited to weekday onsite visits until the client is stabilized as determined by staff. Families are encouraged to contact staff by phone or email to receive updates during the stabilization process. 7. All medications (prescription and non prescription) must be turned into the office. Medications are dispensed as per Program Doctor s orders and Community Care Guidelines. 8. Please encourage the client to contact Last Door Recovery Centre to discuss appropriate items to bring with him to the program. Some clients choose to bring recreational equipment, musical instruments, stereos, etc. Contact Last Door Adult Program 323 8 th Street, New Westminster, BC V3M 3R3 Tel: 604-525-9771 Fax: 604-525-3896 adult@lastdoor.org www.lastdoor.org

REFERRAL SOURCE Referral Date: Made By: Agency: Agency Address: Telephone: ( ) Fax: ( ) How many sessions have you had with the client? CLIENT INFORMATION Age: Date of Birth: Address: Telephone: ( ) Message: ( ) PHN: SIN: CONTACTS A&D Counsellor: Phone: ( ) Family Contact: Phone: ( ) Probation Officer: Phone: ( ) Emergency Contact: Phone: ( ) REFERRAL MOTIVATION Condition of Court Condition of Employment Family Self motivated DETAILS OF FINANCIAL RESOURCES MHSD FAW: Office: Telephone: Private (Fee for Service Contract) Insurance Provider Other

DRUG USE HISTORY: Name Age of first use Method of use Daily Few times per week Four or less times per month Monthly Less than 12 times per year Alcohol Cannabis Cocaine and/or crack Hallucinogens (LSD, Mushrooms, XTC, PCP, etc) Heroin Illicit Methadone Inhalants Meth/amphetamine Nicotine Opiates (ie: morphine, Demerol) Prescription drugs Rave/designer drugs Other COUNSELING EXPERIENCES: Type Withdrawal Services Program Counselor Name Age Length / # of sessions Outcome A & D Outpatient Clinic Psychologist / Psychiatrist Mental Health Residential Treatment Day Treatment Family Counseling

LEGAL INVOLVEMENT: Not involved in CJS On Probation Until? Pending Charge(s): Charged: Does the client have any legal issues associated with inappropriate sexual behavior or fire setting charges? No Unknown Yes MEDICAL AND PSYCHOLOGICAL FUNCTIONING AND HISTORY 1. Has the client experienced any form of physical, sexual, emotional, mental or spiritual abuse?: Yes No Unknown 2. Does the client have a history of aggressive behavior: Yes / No Peers Authority figures Family Spouse Other Describe: 3. Does the client have a history of suicidal ideation or suicide attempts? Yes No Unknown 4. Does the client have a history of self harm / mutilation? Yes No Unknown 5. Is the client prescribed medication? Dosage: Current Diagnosis: Physician: 6. Previous/Suspected Diagnosis (ADHD, ADD, FAE/FAS, OCD, Depression, Anxiety Schizophrenia, Disordered eating, etc): 7. Does the client have any health issues (allergies, heart irregularities, Hepatitis, HIV, Tuberculosis, asthma, head injury, skin conditions, diabetes, nutrition needs, hygiene issues etc)? 8. Is the client displaying any withdrawal symptoms? Yes No Unknown EDUCATION / EMPLOYMENT Grade 12 Completed Expelled Choosing not to attend Currently attending Last grade level enrolled in: University/College Trade School Currently employed No Yes Currently employed No Yes Employer

FAMILY AND SOCIAL HISTORY AND SUPPORT LAST DOOR RECOVERY CENTRE Family supportive of client s treatment: No Yes, Who? Does any family and / or significant others have substance/ problem gambling issues presently/past? No Yes Who? Who does the client want to be involved in his treatment process (healthy peers, social worker, Doctor, mentors, etc? Comments: RELATIONSHIP HISTORY AND SUPPORT Partner supportive of client s treatment: No Yes, Who? Does partner and / or significant other have substance/ problem gambling issues presently/past? No Yes Who? Does the client have children? (Ages Names Gender) Comments: CULTURAL AND SPIRITUAL Describe the client s personal cultural and spiritual interests / beliefs / activities: LEVEL OF MOTIVATION FOR TREATMENT What are the key issues for this client? Do you believe the client is aware of the level of motivation required to participate in a residential program? Yes No Unknown What goals does the client hope to obtain while in treatment (substance misuses issues, educational/vocational, support network etc)? DISHCARGE PLAN: Program complete: Program Incomplete:

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