Rekindling House Dual Diagnosis Specialist
|
|
- Dayna Chapman
- 8 years ago
- Views:
Transcription
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: info@rekindling.co.uk
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
YELDALL MANOR APPLICATION FORM
YELDALL MANOR APPLICATION FORM The information given on this form will not be passed to anyone else, except where this is necessary to process your application. Please write clearly and complete as much
More informationMILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE
MILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS. To register with the Practice please complete this questionnaire as fully as possible.
More informationTHE ROWANS SURGERY MEDICAL HISTORY QUESTIONNAIRE MALE & FEMALE 18+
THE ROWANS SURGERY MEDICAL HISTORY QUESTIONNAIRE MALE & FEMALE 18+ Surname: First Name: Date of Birth: NHS Number: / / Mobile Telephone No: Male / Female If you wish to sign up for Vision On-Line services
More informationPlease make an appointment with the nurse for a new patient medical within one month of joining the practice.
New Patients If you are registering with us as a new patient, please be aware we will need to ask you to provide evidence of identification (ID) as part of the registration process. A combination of two
More information1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840
Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible
More informationReferral Form. What benefits does the applicant receive? allocated?
Please return to Christopher Davies Heantun Housing Association 3 Wellington Road Bilston West Midlands WV14 6AA 01902 571131 christopher.davies@heantun.co.uk Referral Form Personal details: Name of applicant:
More informationPlease find attached an application form, please read the following information before completing the form.
Page: 1 of 12 STEAM MILL BUSINESS CENTRE STEAM MILL STREET CHESTER CH3 5AN TEL: 01244 354700 FAX: 01244 354720 E-MAIL: info@anchorgroup.eu WEB SITE: http://www.anchorgroup.eu Dear Candidate, Re: Job Application
More informationTHE VILLAGE SURGERY - Southwater
ADULT NEW PATIENT HEALTH QUESTIONNAIRE To register with the Practice please complete this questionnaire as fully as possible and let us have it back before your new patient health check appointment with
More informationReferral and Assessment form for adult substance misusers
Referring individuals to substance misuse services Guidance for using the Referral and Assessment form for adult substance misusers and the Comprehensive Care and Review Plan 1 Contents Page 1.0 BACKGROUND
More informationAPPLICATION FORM - ADMINISTRATIVE ASSISTANT
APPLICATION FORM - ADMINISTRATIVE ASSISTANT Please supply 4 recent passport sized photograph of yourself with this application. Full Name:... Telephone No:... Mobile No:... Previous Name(s):... Date of
More informationStatistics on Women in the Justice System. January, 2014
Statistics on Women in the Justice System January, 2014 All material is available though the web site of the Bureau of Justice Statistics (BJS): http://www.bjs.gov/ unless otherwise cited. Note that correctional
More informationSTOPPING DRINKING WITHOUT MEDICATION. Client Registration & Information Pack
STOPPING DRINKING WITHOUT MEDICATION Client Registration & Information Pack CONSENT CONTRACT FEEDBACK COMPLAINTS INSTRUCTIONS PLEASE EITHER: Complete and save and email to me (mark@markjay.co.uk), printing
More informationMental Health Acute Inpatient Service Users Survey Questionnaire
Mental Health Acute Inpatient Service Users Survey Questionnaire What is the survey about? This survey is about your recent stay in hospital for your mental health. Who should complete the questionnaire?
More informationGrant House APPLICATION
Street Haven Addiction Services Grant House APPLICATION Dear applicant, We are pleased you are considering Grant House for treatment and hope in this package to provide more information about our program.
More informationMy health action plan
My health action plan Contents What is a health action plan? 3 Section 1 Personal information 7 Section 2 People who help me 13 Section 3 Communication 17 Section 4 Medicine 23 Section 5 My general health
More informationDate of birth Gender NHS number (if known) Town/Country of birth. Home Telephone no. Work Telephone no.
ADULT - FEB 15 Office use only Staff initials Date ID seen Welcome to Wokingham Medical Centre Thank you for completing this registration form. When registering in person at the surgery please supply two
More informationReview of Drug & Alcohol Services In Derby
Review of Drug & Alcohol Services In Derby Take part from 9 June until 20 July 2014 To take part: Please read the background information contained within this document. If you have any questions about
More informationTitle. Nationality. Email
APPLICATION FORM Devonshire House, 582 Honeypot Lane, Stanmore, Middlesex, HA7 1JS PHONE NO: 020 8906 2001 FAX: 020 8905 6728 LICENSED BY CARE QUALITY COMMISSION Registered in England NO 3414273 PERSONAL
More informationSpecialist Alcohol & Drug Services in Lanarkshire
Specialist Alcohol & Drug Services in Lanarkshire This brochure describes what help is available within Lanarkshire s specialist treatment services. These include the North Lanarkshire Integrated Addiction
More informationKeele Practice New Patient Information
) )Dip/tetanus/polio )1 Keele Practice New Patient Infmation Name Todays date Male/Female University Address Uni tele: Mobile: Date of Birth Home Address email address: Home tele: Significant Medical Histy
More informationPOSTGRADUATE APPLICATION 1
POSTGRADUATE APPLICATION 1 Please read the attached Notes for applicants before completing this form. Please complete form in BLOCK CAPITALS and in black text. PERSONAL DETAILS Have you previously studied
More informationApplication for Admission to the Sussex Masters of Business Administration (MBA)
Application for Admission to the Sussex Masters of Business Administration (MBA) For office use only Please read the attached notes before completing this application form Section A Personal details (Please
More informationFamily doctor services registration
Family doctor services registration GMS1 Patient s details Mr Mrs Miss Ms Date of birth Surname First names Please complete in BLOCK CAPITALS and tick as appropriate NHS No. Male Female Home address Previous
More informationFortrose Medical Practice
Fortrose Medical Practice GP Partners: Dr Sandy MacGregor, Dr Will Fraser, Dr Iain Forth & Dr Jude Watmough Associate GP: Dr Shona Forth Station Road Fortrose Ross-shire IV10 8SY Phone: Fax: Email: Website:
More informationAlcohol and drugs prevention, treatment and recovery: why invest?
Alcohol and drugs prevention, treatment and recovery: why invest? 1 Alcohol problems are widespread 9 million adults drink at levels that increase the risk of harm to their health 1.6 million adults show
More informationLuton Alcohol Strategy 2012-2015
Luton Drug & Alcohol Partnership Luton Alcohol Strategy 2012-2015 The Luton alcohol strategy for 2012 2015 reflects the increasing emphasis on working in partnership to reduce alcohol related harm to young
More information2 Details of course to which you wish to apply
Student No: Application form Solely for applications not handled by the Universities and Colleges Admissions Service (UCAS) or UCAS Teacher Training (UTT). Please read the accompanying Notes for Guidance
More informationHow To Fill Out A Health Declaration
The English translation has no legal force and is provided to the customer for convenience only. The Dutch health declaration should be filled in. Health declaration for occupational disability insurance
More informationNot known. 2) If you currently smoke, would you like to be offered a referral to our Stop Smoking team? Yes No
Specialist Wheelchair Services Specialist Wheelchair Service Referral Form Central London Wheelchair Services 306 Kensal Road London W10 5BE Tel: 0208 962 3939 Fax: 020 8962 3965 Email: clcht.wheelchairs@nhs.net
More informationSheffield Future Commissioning of Drug & Alcohol Community Treatment
Sheffield Future Commissioning of Drug & Alcohol Community Treatment Magdalena Boo, Joint Commissioning Manager Scope of the Plan IN SCOPE Adults 18+ (young people s services are separately commissioned)
More informationHousing List Application
Answer all questions on this form fully & truthfully or your application will be delayed. Please use a black pen and write in BLOCK CAPITALS. If you need help filling in this form please contact 020 7364
More informationNational Drug Treatment Monitoring System (NDTMS) NDTMS DATA SET H
National Drug Treatment Monitoring System (NDTMS) NDTMS DATA SET H BUSINESS DEFINITION FOR ADULT DRUG TREATMENT PROVIDERS Author M. Hinchcliffe Approver M. Roxburgh Date 01/03/2011 Version 8.03 REVISION
More informationGetting help for a drug problem A guide to treatment
Getting help for a drug problem A guide to treatment Who we are The National Treatment Agency for Substance Misuse is part of the National Health Service. We were set up in 2001 to increase the numbers
More informationSOMERSET DUAL DIAGNOSIS PROTOCOL OCTOBER 2011
SOMERSET DUAL DIAGNOSIS PROTOCOL OCTOBER 2011 This document is intended to be used with the Somerset Dual Diagnosis Operational Working guide. This document provides principles governing joint working
More informationAcquired Brain Injury Service for Young People (ABI-YP), National Centre for Brain Injury
Acquired Brain Injury Service for Young People (ABI-YP), National Centre for Brain Injury PLEASE COMPLETE ALL SECTIONS AND RETURN THE FORM TO THE ADDRESS DETAILED ON PAGE 7 NAME OF REFERRER: DESIGNATION:
More informationStudent Statistics. HESA Equality data analysis
Student Statistics HESA Equality data analysis Gender by level and mode In general, as can be seen in the graph below, female students outnumber male students. The exceptions to this were in postgraduate
More informationAssessment shared with: of birth: Name of worker completing assessment: Agency / service: Date risk assessment commenced: Date risk.
For guidance on how to complete this form, workers must refer to the Devon and Torbay Drug and Alcohol Services Risk Assessment and Risk Management Process Guidance Notes. Client name: Client date of birth:
More informationTitle: Mr / Mrs / Miss (Please indicate as appropriate) Other: Surname: Full forenames: Address: Post Code: E-mail: Home Tel No: Mobile Te No:
4 Saxon House Warley Street Upminster Essex RM14 3PJ Tel: 01708 227100 Fax: 01708 250140 Application for Employment 1. Please note that Ultimate Security Services Limited is an equal opportunities employer
More information(Health Scrutiny Sub-Committee 9 March 2009)
Somerset County Council Health Scrutiny Sub-Committee 9 March 2009 Drug and Alcohol Treatment Services Author: Amanda Payne Somerset DAAT Co-ordinator Contact Details: Amanda.Payne@somerset.nhs.uk Paper
More information6. Do you have an Advance Directive or Living Will? Yes No These are written statements about how you want to be treated if you get very sick.
Adult Health History Name: First Last Name you like to be called: Today s Date: Date of Birth: Male Female Transgender Male to Female Transgender Female to Male Other Filling out this form Answering these
More informationMiddlesex University Undergraduate Application Form
Middlesex University Undergraduate Application Form OFFICE USE ONLY Regional ID/ Agent Code: MISIS Student Number: bc This form is only to be used for Direct or Part Time applications only. All other applications
More informationAlcohol Units. A brief guide
Alcohol Units A brief guide 1 2 Alcohol Units A brief guide Units of alcohol explained As typical glass sizes have grown and popular drinks have increased in strength over the years, the old rule of thumb
More information% of time working at heights % What is the average height you work at?
Relevant for Income Protection cases only: 18 Do any of the following form an essential part of your work? a manual work YES NO % of time at Manual work % b Driving YES NO % of time Driving % Average weekly
More informationLife Insurance Application Form
Life Insurance Application Form INSTRUCTION To be completed by all applicants PERSONAL DETAILS Surname First name Middle name Sex Female Male Marital status (please tick) Single Married Other Current residential
More informationSASKATCHEWAN NNADAP TREATMENT SERVICES APPLICATION FORM Revised June, 2009 VAN LOONVCONSULTING
SASKATCHEWAN NNADAP TREATMENT SERVICES APPLICATION FORM Revised June, 2009 VAN LOONVCONSULTING This application is the first step required to pre-screen applicants for adult treatment at any of the NNADAP
More informationCompensation for a personal injury following a period of abuse (physical and/or sexual)
Criminal Injuries Compensation Authority Tay House 300 Bath Street Glasgow, G2 4LN Freephone: 0800 358 3601 For office use only Reference number: Compensation for a personal injury following a period of
More informationNHS Family doctor services registration GMS1
NHS Family doctor services registration GMS1 Patient s details Please complete in BLOCK CAPITALS and tick as Appropriate Mr Mrs Miss Ms Surname Date of birth d d m m y y First names NHS No. Male Female
More informationPERSONAL RECOVERY PROGRAM INTAKE APPLICATION
A Ministry of Phoenix Rescue Mission PERSONAL RECOVERY PROGRAM INTAKE APPLICATION CLC Intake Application 121211 CLC Page 1 of 6 Attention Intake Coordinator 338 North 15 th Avenue, Phoenix, AZ 85007 Phone:
More informationAim of presentation. Drug and Alcohol Services in Leicester. National Policy. Local Policy. Demographics. Aims and objectives of needs assessment
Aim of presentation Drug and Alcohol Services in Leicester Joanne Atkinson, Consultant in Public Health Kate Galoppi, Head of Drug and Alcohol Action Team 19 th June 212 To introduce members to the issues
More informationMedicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
More informationPLEASE READ THIS FORM IN FULL BEFORE COMPLETING IT
Application Form PLEASE READ THIS FORM IN FULL BEFORE COMPLETING IT Please complete all sections of this form when applying for the grant. Please send your completed application form and relevant documentation
More information1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU
CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood
More informationAPPLICATION FOR Page 1/7 RESIDENTIAL TREATMENT
APPLICATION FOR Page 1/7 Instructions: The following form is required to begin the application process to Stonehenge. The form should be printed and completed by hand, then faxed or mailed to Stonehenge
More informationPhysician address. Physician phone
PATIENT QUESTIONNAIRE Name (first, middle initial, last) Address City, State, Zip Social security number Michigan SportsMedicine and Orthopedic Center www.michigansportsmedicine.com Your family physician
More informationNEW Inpatient Treatment Program Application Package
Health and Social Services December 11 th, 2008 MEMORANDUM TO: All Referral Professionals FROM: Dale Gordon Supervisor, Treatment Services Alcohol and Drug Services NEW Inpatient Treatment Program Application
More informationCardiac rehabilitation
Information For Patients & Carers Cardiac rehabilitation Liverpool Heart and Chest Hospital NHS Trust Thomas Drive Liverpool Merseyside L14 3PE Telephone: 0151-228 1616 www.lhch.nhs.uk This leaflet has
More informationEasy Does It, Inc. Transitional Housing Application
Easy Does It Inc. of Reading and Leesport Housing Programs Easy Does It, Inc. Transitional Housing Application Welcome Thank you for applying to Easy Does It, Inc. ( EDI ) a non-profit charitable organization
More informationFamily doctor services registration
GMS1-JUL12_GMS 1 17/07/2012 13:15 Page 1 Family doctor services registration GMS1 Patient s details n Mr n Mrs n Miss n Ms Date of birth Surname First names Please complete in BLOCK CAPITALS and tick n
More informationRequirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges
To: From: Re: Medical Staff Applicants K. Bruce Simmons, MD Director, Requirements for Medical Clearance EMPLOYEE/STUDENT HEALTH Jacobsen Hall 315-464-4260 (telephone) 315-464-5471 (fax) The New York Department
More informationMental Health Needs Assessment Personality Disorder Prevalence and models of care
Mental Health Needs Assessment Personality Disorder Prevalence and models of care Introduction and definitions Personality disorders are a complex group of conditions identified through how an individual
More informationDo you drink or use other drugs? You could be harming more than just your health.
Do you drink or use other drugs? You could be harming more than just your health. Simple questions. Straight answers about the risks of alcohol and drugs for women. 1 Why is my health care provider asking
More informationAlcohol, drugs and older people
Alcohol, drugs and older people This leaflet is for older people (defined as those aged 55 or over) who are worried about their use of alcohol, illegal drugs and/or prescribed/over-the-counter medications.
More informationPlease note that you will not be able to see a doctor or a nurse or obtain any of the free National Health services until you have:
Dr F Docrat and Partners Sparkenhoe Street Leicester, LE2 0TA Tel: 0116 295 7835 Fax: 0116 295 7836 www.shefamedicalpractice.co.uk Dear New Patient, Thank you for your application to join. Please note
More informationPitcairn Medical Practice New Patient Questionnaire
/ / *Areas are mandatory. Failure to complete may delay the time taken to process your registration *Surname: *Forename(s): *Address: *Date of Birth/CHI: / Marital Status: Sex: Male / Female (delete as
More informationDIPLOMA IN DENTAL HYGIENE AND DENTAL THERAPY APPLICATION FORM FOR ADMISSION IN Jan 2016
DIPLOMA IN DENTAL HYGIENE AND DENTAL THERAPY APPLICATION FORM FOR ADMISSION IN Jan 2016 Please complete clearly in BLACK ink Use the information on the website to ensure that you complete this form correctly
More informationTopic Area - Dual Diagnosis
Topic Area - Dual Diagnosis Dual Diagnosis is a challenging problem for both mental health and substance misuse services. People with mental health problems, who also suffer from substance misuse are at
More informationNEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.
DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
More informationApplication for Admission to MSc / PGDip / PGCert Business Psychology
APPLICATION NO: D (for Heriot-Watt University use) Student ID NO: H (for Heriot-Watt University use) Application for Admission to MSc / PGDip / PGCert Business Psychology APPROVED LEARNING PARTNER (ALP)
More informationThe CILEx Compensation Fund Claims Application Form
The CILEx Compensation Fund Claims Application Form Please complete this form to make a claim for a loss you have incurred. When you have filled in the form, please send it to us at: The CILEx Compensation
More informationUse a separate piece of paper if you need any more space for any of your answers but please sign and date it.
Alteration Form NOTES Please read these notes carefully before completing the application form. Please make sure that you: Use blue or black ink; Use BLOCK CAPITALS throughout; Correct and initial any
More informationAdult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
More informationPsychiatric Residential Treatment Facility Referral
Psychiatric Residential Treatment Facility Referral Date of referral: Psychiatric Residential Treatment Facility (PRTF) Referral Information Referral contact: Phone number: Referring facility/agency: Fax
More informationEPIDEMIOLOGY OF OPIATE USE
Opiate Dependence EPIDEMIOLOGY OF OPIATE USE Difficult to estimate true extent of opiate dependence Based on National Survey of Health and Mental Well Being: 1.2% sample used opiates in last 12 months
More informationMVA Accident Questionnaire
MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK
More informationDirectory for Substance Misuse Services in Caerphilly
Directory for Substance Misuse s in Caerphilly Background Substance Misuse services use a tiered approach in their approach and delivering of drug/alcohol services. These are as follows: Tier 1 Interventions
More informationNEW PATIENT REGISTRATION
Title Mr / Mrs / Ms / Miss / Master / Dr Surname Given Names Address Postcode. Date of Birth. Age Occupation Telephone H.. M. W.. Next of Kin:. Tel:.. Referring Dr. Address.. Private Insurance YES / NO
More informationLike cocaine, heroin is a drug that is illegal in some areas of the world. Heroin is highly addictive.
Heroin Introduction Heroin is a powerful drug that affects the brain. People who use it can form a strong addiction. Addiction is when a drug user can t stop taking a drug, even when he or she wants to.
More informationDual Diagnosis. Dual Diagnosis Good Practice Guidance, Dept of Health (2002);
Dual Diagnosis Dual Diagnosis is a challenging problem for both mental health and substance misuse services. People with mental health problems, who also suffer from substance misuse are at an increased
More informationNational Offender Management Service NOMS Reducing Re-offending: Drug and Alcohol Treatment Strategy
National Offender Management Service NOMS Reducing Re-offending: Drug and Alcohol Treatment Strategy Danny Clark, Head of Substance Misuse interventions Reducing Re-offending Policy Group Directorate of
More informationNew Port Centre. 5. DHQ Drug History Questionnaire 6. Adverse Consequences Questionnaire 7. Tracking Sheet With Scores of Other Provincial Assessments
New Port Centre Page 1 of 2 NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne ON, L3K 2N7 Phone (905) 378-4647 Ext 32500 Fax: (905) 834-3002 E-mail: NewPortAdmin@niagarahealth.on.ca
More informationMilton Keynes Drug and Alcohol Strategy 2014-17
Health and Wellbeing Board Milton Keynes Drug and Alcohol Strategy 2014-17 www.milton-keynes.gov.uk 2 Contents Foreword 4 Introduction 5 National context 6 Local context 7 Values and principles 9 Priorities
More informationPARTNERS IN PEDIATRIC CARE. Intake and History for Mental Health Referral
PARTNERS IN PEDIATRIC CARE Intake and History for Mental Health Referral This form is designed to give you an opportunity to provide us with background information that will help us help you. Please read
More informationProvidence Alliance for Catholic Teachers (PACT)
Providence Alliance for Catholic Teachers (PACT) Health and Wellness History Please place this form in a separate sealed envelope, marked with your name and Health and Wellness History. Submit to PACT
More informationPOINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
More informationMEDICAL HISTORY AND SCREENING FORM
MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems
More informationAlcohol. Problems with drinking alcohol
Alcohol Alcoholism is a word which many people use to mean alcohol dependence (alcohol addiction). Some people are problem drinkers without being dependent on alcohol. If you are alcohol- dependent then
More informationAlcohol and Young people
The facts about... Alcohol and Young people Five key things you need to know There s good news. And there s bad. Despite what the headlines often lead us to believe, the number of teenagers who are drinking
More informationHOSC Report Integrated community drugs and alcohol service retendering options beyond April 2016
HOSC Report Integrated community drugs and alcohol service retendering options beyond April 2016 Meeting Date Sponsor Report author Purpose of report (summary) 12 th May 2015 Margaret Willcox Steve O Neill
More informationSurname: Postcode: I can attend each day of the Summer School and all 16 Saturday sessions. I have completed all information in sections A, B, C and D
CHOICE Study with the world s leading Social Science institution Summer School: Monday 17 Friday 21 August 2015 16 Saturday Sessions: 19 September 2015 5 March 2016 Deadline Friday 20 March 2015 First
More informationStudent & Health Information for Bates College Off-Campus Short Term Courses
Student & Health Information for Bates College Off-Campus Short Term Courses 1. Name Program/Course Bates ID # Email Cell phone: Home Address: Date of Birth Nationality If course is going abroad, attach
More informationAlcohol Awareness Month October 2013. Chad Asplund, MD, FACSM Medical Director, Student Health Georgia Regents University
Alcohol Awareness Month October 2013 Chad Asplund, MD, FACSM Medical Director, Student Health Georgia Regents University Alcohol Statistics According to the Office of Juvenile Justice and Delinquency
More informationAPPLICATION FOR ADMISSION
APPLICATION FOR ADMISSION Check One: Phase I Family program Calgary Drug Treatment Court PERSONAL INFORMATION Admission completed by Date Name Last First Middle Address Street number City Province Postal
More informationBrantford Native Housing Residential Support/ Addiction Treatment Program
Brantford Native Housing Residential Support/ Addiction Treatment Program Application Package Ojistoh House or Karahkwa House 318 Colborne Street East Brantford, ON N3S 3M9 (519) 753-5408 x 235 T (519)
More informationDear Incoming Student:
FOR THE ADVANCEMENT OF SCIENCE AND ART Dear Incoming Student: It is mandatory that you complete and return the enclosed Cooper Union health forms and the New York State required response forms for Meningitis,
More informationFrequently Asked Questions (FAQs) of Drug Abuse Treatment for Criminal Justice Populations
Frequently Asked Questions (FAQs) of Drug Abuse Treatment for Criminal Justice Populations From The National Institute on Drug Abuse (NIDA) 2. Why should drug abuse treatment be provided to offenders?
More informationDrug Treatment - A Comprehensive Report for the UK Police
Drug treatment performance summary CCG Board January 214 Prevalence 3, 2, 1, 242 2424 opiate and/or crack.. upper & lower CI's Prevalence of crack and opiate use is down. 1866 8-9 9-1 1-11 Similar to the
More informationHow To Use Theseus
Drug and Alcohol Fair Processing Notice Contents Introduction What information is held? Who can access the information? How is the information used? Who else is this information passed to? How is information
More information(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _
2302 N. Stockton Hill Rd Ste. G 1731 Mesquite Ave Ste 4 1200 Mohave Rd MEDICAL HISTORY Weight: Shoe size: ~~~~~~~~~~~~~~~~~~~~~~~~~~PLEASECIRCLE: RIGHT or LE~ Is your problem due to an accident? YES or
More informationFull Equality Impact Assessment Pro- forma (Stage 2)
Full Equality Impact Assessment Pro- forma (Stage 2) Group: Care, Wellbeing and Learning Service: Public Health Section: Public Health Officer responsible for assessment: Carole Wood Support officers:
More informationCorl Kerry - Referral and Assessment for Residential Treatment (Tier 4) Introduction Types of Tier 4 Services Services provided at Tier 4
Corl Kerry - Referral and Assessment for Residential Treatment (Tier 4) This document seeks to name the criteria that can guide referrals to residential tier 4 facilities (Part A). It provides guidance
More information