CORE ADDICTION ASSESSMENT / ADMISSION PACKAGE. Date of Birth: Day Month Year

Transcription

1 Windsor Addiction Assessment & Outpatient Service Tayfour Campus, Withdrawal Management & Assessment Centre 1453 Prince Road, Windsor, Ontario N9C 3Z4 Phone: Fax: CORE ADDICTION ASSESSMENT / ADMISSION PACKAGE Name: Male Female Address: City: Phone Number(s): Postal Code: Message allowed? Date of Birth: Day Month Year Age: Health Card Number: Referred by: Emergency Contact: Version code initials: Date referred: Emergency Number: What type of service are you seeking? Addiction Assessment Referral to Addiction Treatment Only to comply with 3 rd party requirement Other: (If other, please explain) Important Please read before you begin Please complete this package when you are alcohol / drug free for at least 12 hours. Read all instructions carefully and write your answers in pen, not pencil. Please do not leave any blanks as this may delay services. If you have any difficulties filling out these forms, you may get help from a 3 rd party; however, it is important that all the answers are your own. After we receive your completed package, one of our staff will contact you to book an individual assessment appointment.

2 Please check the appropriate box, unless otherwise instructed. Have you ever been a client of this agency before: Yes No Basic Problem: (Check all that apply) Alcohol Drugs Gambling Legal obligation Psychiatric Codependency Other Past & Present Addiction Treatment: Check all that apply None Detox Methadone Out-Patient Residential Self-Help Support Groups Concurrent Disorder Treatment mandated/required by: None Regain child custody Condition of family Employment Condition Condition of Probation/Parole Current Legal Status: No problems On probation/parole Awaiting trial/sentencing: Relationship Status: Married/partnered/C/L Widowed Separated/divorced Single Employment Status: Full time/self employed Student/retraining Disabled Retired Employed part time Not in labour force Unemployed/looking for work Education: (elementary, high school, college, university) Income Source: Employment Ontario Works ODSP None E. I. Retirement Income Family Support Other Do you have a gambling problem? Yes No Do you have any special needs? (vision, hearing, mobility) Yes No If yes, please specify Non-medical intravenous IV use: Never injected Injected within last 12 months injected over 1 year ago Have you been diagnosed with a psychiatric condition? If yes, what is your diagnosis? Are you pregnant? Yes No

3 Substances: Used in the Past Year? Yes / No Check only one (1) box to show how often you used a substance in the past 30 days. Did not use 1 3 Times 1 2 Times Weekly 3 6 Times Weekly Daily Binge Use Is your use a problem? Yes / No Alcohol Cocaine / Crack Amphetamines / Other Stimulants Cannabis (hash, hash-oil, pot, weed, grass, marijuana) Benzodiazepines / Tranquilizers (Serax, Ativan, Valium, etc.) Barbiturates (Sleeping Pills) Heroin Opioids / Pain Pills (Oxycontin, Percocet, Morphine, etc.) Over the Counter codeine (Tylenol #1) Hallucinogens (Acid, LSD, Mushrooms, XTC) Inhalants (glue, gasoline) Tobacco Other Psychoactive Drugs (Anti-depressants, steroids, any others not mentioned above)

4 BASIS-32 (Behavior and Symptom Identification Scale) INSTRUCTIONS: Below is a list of problems and areas, some people have difficulties with. Using the scale below (0-4), please assign a number that describes how much difficulty you have been having in the past week or so. Do not leave any blanks. 0 = No difficulty at all 1 = A little bit of difficulty 2 = Some difficulty 3 Quite a lot of difficulty 4 = Extreme Difficulty In the past week, how much difficulty have you been having in the area of 1. Managing day to day life (e.g. getting to places on time, handling money, making every day decisions) 2. Household responsibilities (e.g. shopping, cooking, laundry, cleaning, other chores) 3. Work (e.g. completing tasks, performance level, finding/keeping employment) 4. School (e.g. academic performance, completing assignments, attendance) 5. Leisure time or recreational activities 6. Adjusting to major life stressors (e.g. separation/divorce, moving, new job, new school, a death) 7. Relationships with family members 8. Getting along with people outside the family 9. Isolation or feelings of loneliness 10. Being able to feel close to others 11. Being realistic about yourself or others 12. Recognizing and expressing emotions appropriately 13. Developing independence, autonomy 14. Goals or direction in life 15. Lack of self-confidence, feeling bad about yourself 16. Apathy, lack of interest in things 17. Depression, hopelessness 18. Suicidal feelings or behaviour 19. Physical symptoms (e.g. headaches, aches & pains, sleep disturbance, stomach aches, dizziness) 20. Fear, anxiety, or panic 21. Confusion, concentration, memory 22. Disturbing or unreal thoughts or beliefs 23. Hearing voices, seeing things 24. Manic, bizarre behaviour 25. Mood swings, unstable moods 26. Uncontrollable, compulsive behaviour (e.g. eating disorder, hand washing, hurting yourself) 27. Sexual activity or preoccupation 28. Drinking alcoholic beverages 29. Taking illegal drugs, misusing drugs 30. Controlling temper, outbursts of anger, violence 31. Impulsive, illegal, or reckless behaviour 32. Feeling satisfied with your life

5 Treatment Entry Questionnaire Instructions: Please indicate whether you agree or disagree with each of the following statements by placing the number that best reflects your own personal opinion in the blank provided. Remember there, are no right or wrong answers, and your responses are completely confidential. Use the following scale to make your ratings: Strongly DISAGREE Strongly AGREE 1. I decided to enter a program because I was interested in getting help 2. I decided to enter a program because I won t like myself very much unless my substance abuse problem is under control 3. If I remain in treatment it will probably be because others with be angry with me if I don t 4. I decided to enter a program because I really want to make some changes in my life 5. I plan to go through with treatment because I ll be ashamed of myself if I don t 6. The reason I am in treatment is because other people have pressured me into being here 7. If I remain in treatment, it will probably because I ll feel like a failure if I don t 8. I decided to enter a program because it is important for me to deal with my substance abuse problem 9. I have agreed to enter a program because I ll get into trouble with my friends/family if I don t 10. I plan to go through with a treatment program because I don t want to abuse alcohol and drugs 11. If I remain in treatment it will probably be because I ll feel very bad about myself if I don t 12. I have agreed to follow a treatment program because I was pressured to come Perceived Social Support Instructions: the statements which follow refer to feelings and experiences which occur to most people at one time or another in their relationships with family or friends. For each statement there are three possible answers: Yes, No, Don t know. Please check the answer you choose for each item. Family Items Yes No Don t Know 1. My family gives me the moral support I need 2. Most other people are closer to their family than I am 3. I rely on my family for emotional support 4. My family and I are very open about what we think about things 5. My family is sensitive to my personal needs 6. Members of my family are good at helping me solve problems 7. I wish my family were much different Friend Items 1. My friends give me the moral support I need 2. Most other people are closer to their friends than I am 3. I rely on my friends for emotional support 4. My friends and I are very open about what we think about things 5. My friends are sensitive to my personal needs 6. My friends are good at helping me solve problems 7. I wish my friends were much different

6 Windsor Regional Problem Gambling Services DSM IV Questionnaire Please answer yes or no to every question with regards to your gambling in the past year: /10 I am (or have been) preoccupied with gambling (I relive past gambling experiences, plan the next venture or am thinking of ways to get money with which to gamble. I need to gamble with increasing amounts of money in order to achieve the desired excitement. I have had many unsuccessful efforts to control, cut back, or stop gambling. I am (or have been) restless or irritable when attempting to cut down to stop Gambling. I gamble (or have gambled) as a way of escaping from problems or of relieving an unpleasant mood (e.g. feelings of helplessness, guilt, anxiety or depression). After losing money gambling, I often return another day to get even. I have lied to family members, therapists, or others to conceal the extent of involvement with gambling. I have committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling. I have jeopardized or lost a significant relationship, job, or educational, or career opportunity because of gambling. I have relied on others to provide money to relieve a desperate financial situation caused by gambling. Total yes answers

7 Health Screening Do you think you require emergency medical attention? Yes No If yes, contact your family doctor or nearest Hospital Emergency Department immediately. Do you think about hurting yourself or others? Yes No If yes, contact Hotel Dieu Grace Hospital Crisis line at , or go directly to a hospital Emergency Department immediately. Family Doctor? Phone: Last seen: Psychiatrist? Phone: Last seen: Psychologist/Therapist/Counsellor: Phone: Last seen: Have you ever been diagnosed with a psychiatric illness, including any of the following;- Schizophrenia Bi-polar Depression Anxiety Other: Have you been admitted into a hospital in the last year? Yes No If yes, for what reason? Current prescribed medications (include dose amounts and the reason for taking it) Physical Health Conditions / Problems (check all boxes that apply) Allergies (including drug allergies) Blood Pressure Problems Cancer Chronic Pain Diabetes Eating disorders / problems HIV / AIDS Heart Disease Hepatitis A, B, or C History of head injuries Jaundice Kidney Disease Lice / Scabies Liver Disease Menstrual / Menopausal difficulties Pancreatitis Respiratory problems STD (Sexually transmitted disease) Stomach / Gastrointestinal problems Thyroid problems TB (Tuberculosis) Other If you have checked off other, please describe:

8 Windsor Addiction Assessment & Outpatient Services Consumer Rights Please read the following consumer rights statements below. As a consumer of the Addiction Assessment & Outpatient Services, it is your right to be informed. When you have read these rights, please sign the bottom of this page to verify your knowledge of these rights. As a consumer of the Addiction Assessment & Outpatient Service, you have the following rights;- 1. To be treated with dignity and respect by all of the staff who serve you. 2. To have a plan of care, specifically designed to meet your treatment needs. 3. To participate in the development of that plan of care. 4. To review that plan, and to have that plan updated and evaluated as appropriate. 5. To expect quality service from all members of the treatment staff, and to expect the assessment and treatment staff to be competent, qualified and professional. 6. To expect all client information to be kept confidential. 7. To review your assessment and treatment records in a scheduled appointment with appropriate staff. 8. To refuse services 9. To be served without regard to race, colour, national origin, religious beliefs, sexual orientation, etc. 10.To lodge a complaint to state a grievance at any time; first to staff, the program manager if unresolved, and the patient representative if necessary, and expect that this concern will be respected and acted upon. I have reviewed the Consumer Rights statements above and I understand what they mean. I understand that these rights are guaranteed to me as a recipient of the Windsor Addiction Assessment & Outpatient Service and that I can gain more information regarding my rights by contacting a Recipient Rights Advisor/Ombudsman. Consumer Signature Date

9 Windsor Addiction Assessment & Outpatient Services Consumer Responsibilities As a consumer of the Windsor Addiction Assessment & Outpatient Services, I have certain responsibilities, which include the following;- 1. The responsibility to help develop my plan for treatment. 2. The responsibility to sign any forms necessary for the release of information in my client record since the staff of Windsor Addiction Assessment & Outpatient Services cannot give out this information without my permission except in the case of an emergency. 3. The responsibility to suggest changes for the improvement of the Windsor Addiction Assessment & Outpatient Services when appropriate. 4. The responsibility to be on time for scheduled appointments or provide advanced notice of appointment cancellation. 5. The responsibility to observe the Windsor Addiction Assessment & Outpatient Services rules and regulations. 6. The responsibility to comply with the provisions of my treatment plan arrangements. 7. The responsibility to provide accurate information regarding my care. Also, as a consumer, I may be discharged from Windsor Addiction Assessment & Outpatient Services for the following reasons;- 1. When I have completed the planned course of treatment with an acceptable degree of success. 2. When I choose to terminate treatment. 3. When the counsellor feels that termination is the most reasonable option given any particular response to treatment 4. If I bring alcohol, mood altering chemicals, or a weapon on the premises. 5. If I initiate or participate in any form of violence (or perceived threat of violence on the premises. 6. If I disclose the identity and or information of any other consumer of the Windsor Addiction Assessment & Outpatient Services. 7. If I refuse to comply with the treatment plan agreed upon between myself and my worker. 8. If I repeatedly miss appointments, reschedule appointments, or repeatedly attend appointments late. 9. If I fail to comply with the rules & regulations of Windsor Addiction Assessment & Outpatient Services 10. If I move out of the service area. I understand that I have the right to discuss any or all of the above with staff. Consumer Signature Date