Rekindling House Dual Diagnosis Specialist

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1 Rekindling House Dual Diagnosis Specialist Tel: APPLICATION FOR TREATMENT Application Form / Comprehensive Assessment Form Please provide as much detail as you can it will help us process your application Ask your Care Manager, CARAT Worker or Drug Worker for help if you need it. First Surname: Preferred Name (if different): Date of Birth: Age: NI Number: Male: Female:

2 Support Network Role Name Address Tel No & E mail GP Care Manager Community Prescriber If applicable Probation Officer Next of Kin Permission to contact in emergency? Other e.g. children s social worker Housing status ( ) NFA: Housing problem: No Housing problem: Your Current Address: Postcode (or part postcode) Most Recent Address (If different): Postcode (or part of postcode) Home telephone number: Mobile number: address: Can we contact you at your current address? Ethnic Origin: Please state if NFA Country of birth: White: Mixed: Asian/Asian British Black/Black British Other British White & Black Caribbean Indian Caribbean Chinese Irish White & Black African Pakistani African Any Other Other White & Asian Bangladeshi Other Refused Other Other Religion: Yes / No Employment Status: Rekindling Jan 2013/v.1 2

3 Are you currently in receipt of Benefits? If yes, name of benefit and post office where paid Currently receiving Housing Benefit? Financial assessment completed with care manager? Contribution required from benefits? (Top up) Yes / No Yes / No Yes / No Must be discussed with Care Manager and agreed with client prior to admission Have you ever had treatment for your drug/alcohol problem before? Yes / No If yes, was this: (tick all that apply) GP/ Specialist Prescribing Detox Day Programme How was your experience of this treatment (s)? Prison Programme Rehab Other Are you engaged in any Preparation for treatment programme offered to you? Yes No Not on offer Part One Current Substance Use Main Problem Drug: Second Problem Drug: Third Problem Drug: Age first used: Age first used: Age first used: Quantity How much? How much? How much? Frequency How often? How often? How often? Pattern of Every day or binges? Every day or binges? Every day or binges? Rekindling Jan 2013/v.1 3

4 use Route How do you take it? How do you take it? How do you take it? Source Where do you get it? Where do you get it? Where do you get it? Opiate Substitute Prescribing Are you currently being prescribed an opiate substitute, if so what is it? e.g. Methadone, Subutex What is your daily dosage? Who prescribes it? Are you on daily pick up? Yes / No Supervised consumption? Yes / No How long have you been prescribed it? Over the Counter Medications Are you regularly taking medicines you buy at the pharmacy? What are they? What dosage and how often? Why are you taking them? How long have you been taking them? Do you believe you are dependent on them? Quantity & Type Current Alcohol Use: What do you drink and how much? How many units? Frequency Severity of dependence How often do you drink, daily or binges? Do you get any symptoms if you don t have a drink? How many days in the last 28 have you consumed alcohol? Have you ever had a seizure related to alcohol withdrawal? Above safe levels? (3-4 units per day for men, 2-3 units per day for women) Rekindling Jan 2013/v.1 4

5 1 unit = half pint normal strength (3.5%) Beer / Lager / Cider, 25ml measure of spirits or one small (125ml) glass wine Substance Misuse History: Have you injected anything in the last 30 days? Have you shared injecting equipment? How do you fund your drug or alcohol use? Sex worker status: Street / Premises / Past history of / Not Known / Not a sex Worker Do you want to tell us anything else about your drug or alcohol use? Part Two Physical Health Epilepsy Asthma Diabetes Liver Disease Pregnant Allergies Any other current illnesses or symptoms? If yes, please give details: Are you taking any prescribed or over the counter medications not already mentioned Rekindling Jan 2013/v.1 5

6 (drug name, dose, frequency, what for) Do you smoke cigarettes? Do you have dental problems? Any weight loss? Height: Weight: Blood Borne Viruses if applicable Tested? Result? Latest test date: (year if no date) HIV Yes No +ve -ve Hep B Yes No +ve -ve Hep C Yes No +ve -ve TB Yes No +ve -ve Vaccinations Have you had any of these? if applicable Hep A Date: Hep B Vac1 Vac 2 Vac 3 Date: TB Date: Tetanus Date: Any other Date: History of fits/blackouts Drug Smokers How do you smoke? (foil/pipe/joint/other) Wheeze Breathlessness Cough Coughing anything up? Coughing up blood? Chest pain? Drug Injectors Do you inject now or have you ever injected? Have you had any Injecting problems? History of skin infection / cellulitis / ulcer / abscess History of septicaemia (blood poisoning) / endocarditis (infection in the heart) History of DVT / PE / Other thrombosis (blood clot in leg / lung / anywhere else) Psychological Health Personality Problems or Disorders Self Harm (include last episode and nature of harm) Suicide Attempts (include type and dates) History of abuse or trauma Depression Anxiety Disordered patterns of eating Diagnosis of psychiatric co-morbidity Family history of mental illness Contact with Mental Health Services (include agency details) Capacity under the Mental Health Act 2005 If you have ticked any of the above please provide details. Rekindling Jan 2013/v.1 6

7 Do you want to tell us anything else about your physical or psychological health? (Please include your own opinions as well as those of any professional you may have seen.) Rekindling Jan 2013/v.1 7

8 Part Three Childcare issues Problems with Partner Domestic violence Problems with Family Problems with Housing Problems with Education Literacy/numeracy Problems Problems with Employment Problems with Benefits Financial problems (Is top up required?) Brief personal / family history and significant relationships: Rekindling Jan 2013/v.1 8

9 Parental Status (Delete as appropriate) Not a parent / Children in care / Children living with partner Dependent Children Child 1 Main Carer Tick if child on at risk register Child 2 Main Carer Child 3 Main Carer Child 4 Main Carer Child 5 Main Carer If more space is needed, please continue on a separate piece of paper Details of any other children, e.g. partners children, whose care you are involved in: (Name, age, arrangements/concerns, on At risk Register?) Cultural Issues: (any cultural, sexual, physical, spiritual or dietary needs that need to be taken into account when completing a treatment plan) Rekindling Jan 2013/v.1 9

10 Part Four Criminal activity that pre-dates substance misuse Family history of offending Recent arrests Past prison sentences Fines Outstanding charges / warrants (Include pending court dates) Probation involvement Recent imprisonment Violent offences Sexual Offences Arson offences Ongoing criminal activity Involvement with criminal justice workers Is there any other information you think might be useful for us to know? Rekindling Jan 2013/v.1 10

11 How do you think you might try to sabotage your treatment with us? If you wish to do so, please use this space to add any other comment you wish to make in support of your application: Form completed by:.... Date:. Care Managers signature:. Date:. Rekindling Jan 2013/v.1 11

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