Family Treatment Centre Prince Albert Parkland … ACASTSP...2014/11/03  · Family Treatment Centre...

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Family Treatment Centre Prince Albert Parkland Health Region 1200-24 th Street West Prince Albert, Sask. S6V 5T4 Ph: 1 (306)765-6375 Fax: 1(306)763-4670 FAMILY TREATMENT REFERRAL INFORMATION Program The Family Treatment Centre is a 6 week inpatient addictions treatment facility for females with dependent children where childcare is a barrier to treatment. The primary focus of the Family Treatment Centre is treatment for addiction. The underlying philosophy of the Centre is holistic, gender responsive and we recognize the need to provide trauma informed care. The Centre provides a safe supportive environment for clients to work on recovery. Clients will receive life skills coaching and parenting support during the inpatient stay. A goal of treatment is to provide strategies and support what will reduce the negative impact substance use is having on their lives and the lives of their children. Mothers and children have specialized living quarters which enables them to live together as a single family unit. Mothers have access to professional daycare while they are in programming. Who do we serve? This a provincial resource for women with young children where childcare is a barrier to treatment Women and their children entering treatment will be provided the appropriate care and support. Priority will be given to those: Clients that are pregnant or nursing. Client at high risk for relapse. Things to consider in the Referral Process: - Acute withdraw must be completed before intake. - The parent must have custody of the children. - Children must be able to stay with the parent in treatment for the 6 week stay. - We can accommodate children from the ages of 0-12 years. - Clients can actively be receiving methadone treatment. - Clients cognitive ability and mental health should be such that they will be able to participate in the treatment program. - Court involvement must be indicated prior to admission. - Criminal history must be indicated prior to admission - The importance of a strong discharge plan is critical to increase the effectiveness of treatment therefore discharge planning (identifying community supports) should begin to occur prior to admission. We thank you in advance for completing an appropriate and thorough assessment, as this will allow us to support the clients on their journey in recovery. Should you require further information please contact our Family Treatment Centre at 765-6375. 1 Revised May 3, 2013

Transcript of Family Treatment Centre Prince Albert Parkland … ACASTSP...2014/11/03  · Family Treatment Centre...

Page 1: Family Treatment Centre Prince Albert Parkland … ACASTSP...2014/11/03  · Family Treatment Centre Prince Albert Parkland Health Region 1200-24th Street West Prince Albert, Sask.

Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

FAMILY TREATMENT REFERRAL INFORMATION

Program The Family Treatment Centre is a 6 week inpatient addictions treatment facility for females with dependent children where childcare is a barrier to treatment. The primary focus of the Family Treatment Centre is treatment for addiction. The underlying philosophy of the Centre is holistic, gender responsive and we recognize the need to provide trauma informed care. The Centre provides a safe supportive environment for clients to work on recovery. Clients will receive life skills coaching and parenting support during the inpatient stay. A goal of treatment is to provide strategies and support what will reduce the negative impact substance use is having on their lives and the lives of their children. Mothers and children have specialized living quarters which enables them to live together as a single family unit. Mothers have access to professional daycare while they are in programming. Who do we serve? This a provincial resource for women with young children where childcare is a barrier to treatment Women and their children entering treatment will be provided the appropriate care and support.

Priority will be given to those: Clients that are pregnant or nursing. Client at high risk for relapse.

Things to consider in the Referral Process:

- Acute withdraw must be completed before intake. - The parent must have custody of the children. - Children must be able to stay with the parent in treatment for the 6 week stay. - We can accommodate children from the ages of 0-12 years. - Clients can actively be receiving methadone treatment. - Clients cognitive ability and mental health should be such that they will be able to participate in the treatment program.

- Court involvement must be indicated prior to admission. - Criminal history must be indicated prior to admission - The importance of a strong discharge plan is critical to increase the effectiveness of treatment therefore discharge planning (identifying community supports) should begin to occur prior to admission.

We thank you in advance for completing an appropriate and thorough assessment, as this will allow us to support the clients on their journey in recovery. Should you require further information please contact our Family Treatment Centre at 765-6375.

1 Revised May 3, 2013

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

ADMISSIONS OVERVIEW: The Family Treatment Centre accepts referrals from Outpatient Addictions Services throughout the

province of Saskatchewan – both on and off reserve.

Admissions to the Family Treatment Centre are contingent on the availability of pre and post treatment counseling and follow up.

Referrals must be complete and will be reviewed by intake. Any missing information will be requested before a client can be placed on the wait list.

After acceptance into the family treatment program an intake date will be given to the referring worker/ Client.

SPECIFIC PRE-ADMISSION REQUIREMENTS Acute withdrawal must be complete before intake.

Clients must have a residence to return to after completion of treatment and post-treatment support should be identified prior to intake.

Families must not have pre scheduled appointments or obligations that will require absence from the Family Treatment Centre (i.e. Court appearances, doctor appointments etc.).

Clients must be prepared and able to participate in the programming and counseling as required.

Family Treatment Center is not under any obligation to accept a person who has been legally ordered to attend the Inpatient program.

Admission/ Discharge travel arrangements (to and from the Family Treatment Center) must be in place prior to admissions.

Clients will be given a date and time of arrival for treatment and it is important to attend at the scheduled time. If a client encounters any unforeseen delays, please call us at 765-6375 to us know of your expected time of arrival.

All school aged children are encouraged to bring schoolwork that is deemed important by their school/teachers. Educational support will be provided to children to assist them in completing work that is provided to them during their 6 week absence from their regular school.

MEDICAL PRE-ADMISSION REQUIREMENTS

Clients must not require medical detox from alcohol and drugs. A pre-admission medical must be completed on adults only, unless a child has a known illness.

Clients must have a valid Personal Health Care Number. .

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

The following information is required prior to any client being placed on our waiting list. Please ensure all information on these forms has been completed before sending. Requests for admissions

should contain a Provincial Mental Health and Addictions Primary Assessment Form.

1. CLIENT INFORMATION:

Client’s Legal Name: DOB: Age: _ __

# of Children planning to attend:____________

Address: Postal Code: ___________________

Home phone #: ____ Cell phone #: __________________

SK Health #: ____ Treaty #: _____ Marital Status: Married Separated Divorced Single Common Law Next of Kin to be notified in case of Emergency:

Name: ___________________________ Relationship to client: _________________________ Home phone #: __________________________ Cell phone #: __________________________

Please provide a brief explanation of the client’s motivation and purpose in seeking treatment at the Family Treatment Centre. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. REFERRING AGENCY INFORMATION: Name: _____________________________ Agency: _____________________________ Contact #: __________________________ Address: ___________________________ Postal Code: ____________________________ Please give a brief statement of your client’s strengths and goals. Include rationale for the referral to Family Treatment Centre and assessment of client’s readiness for residential treatment. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

LEGAL INFORMATION: Is your client involved with the Criminal Justice System? Yes No If yes, is your client currently on probation or parole? Yes No ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Does your client have any upcoming court appearances? Yes No If yes, please indicated date: _______________________

**Please be aware that clients will not be given permission to be absent from the program for court appearances, as we expect that all court appearances will be dealt with prior to entering treatment** Name of Probation/ Parole Officer: ___________________ Contact #: ____________________ Name of Social Services Worker: _____________________ Contact #: ____________________ Do you or your children have gang affiliation? Yes No If yes, please explain: ______________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ 3. MENTAL HEALTH INFORMATION: Does your client have a history of Mental Illness? Yes No If yes, what Mental Health conditions has the client been treated for by a Mental Health professional during her life-time? Depression Sleep Disorder Psychosis Schizophrenia Substance Related Disorder Conduct Disorder Bi-Polar Dissociative Disorder Eating Disorder Anxiety Personality Disorder Impulse Control Other: ___________________

Please provide any additional information on client’s Mental Illness: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

MEDICAL INFORMATION: Physician Name: ____________________________ Phone #: ________________________ Methadone Physician Name: ___________________ Phone #: ________________________ Psychiatrist Name: ___________________________ Phone #: ________________________ Other: _____________________________________ Phone #: ________________________ Does your client have any previous medical concerns? (High Blood pressure, diabetes, history of seizures, strokes, etc.) If yes, please explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Does your client have special health care needs? (Mobility issues: walking, bending, sitting, etc.) If yes, please explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Allergy Information (food, medical, animal, special dietary requirements): _____________________ __________________________________________________________________________________________________________________________________________________________________________ Is your client currently pregnant? Yes No Expected due date: __________________ If yes, is the client receiving prenatal care? Yes No If yes, please explain: __________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ Is the client on the methadone maintenance program? Yes No If yes, please indicate: Current dose: _______ ml Length of time on dose: _______ Months/ Years ** If yes, incoming clients must arrange at least 6 weeks of methadone prescriptions to be brought upon arrival. Client must be stabilized on this dose for at least 3 months ** I understand that the Family Treatment Centre is a Full 6 week Program and it is mandatory to attend and participate in all aspects of programming.

__________________________________ ___________________________________ Client’s Signature Referring Agent’s Signature

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

CHILD REGISTRATION FORM: (1 per child) Child’s Full Name: ____________________________ HSN# _______________________ Birth Date: _________________ Age: _______ Gender: __________________ Family Physician: __________________________ Contact #: _________________ Medical Information: Child’s Diagnosis: _____________________________________________________________________ Medications: __________________________________________________________________________ _____________________________________________________________________________________ Allergies (food, medical, animal, or otherwise): ______________________________________________ _____________________________________________________________________________________ Immunization (have you chosen to immunize your child): Yes No Education Information: School Attending: ____________________________ Contact #: __________________________ Teacher’s Name: __________________________ Grade: ___________________ ** School aged children must bring English, Mathematics or any other school work that is deemed important by their school teacher to have completed during their 6 week absence from their regular school. There will be a Teacher on site. ** Psychological History: Has your child experienced or been exposed to any of the following, please indicate past or present: Depression Past Present Death/ Grief/ Loss Past Present Anxiety Disorders Past Present Panic Disorders Past Present Phobias Past Present Abuse (Physical, Emotional, Mental, Sexual) Past Present Relationship problems at home Past Present Relationship problems at school Past Present Drug problems Past Present Alcohol problems Past Present Violence or Anger problems Past Present Suicide Past Present Difficulty at school Past Present Physical harm to others (people or others) Yes No Conflict with the Law Yes No Other: ___________________________________

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

Emotional & Physical Skills, Challenges and Interests Child’s strong likes: _____________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Strong dislikes: ________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Child’s strengths: _______________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Weaknesses or things child finds hard to do: __________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Social Behavior: Children often show how they feel by what they do and not what they say. What does your child do when he or she is stressed or upset? ____________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ What is the best way to help your child calm down or relax? ____________________________________ __________________________________________________________________________________________________________________________________________________________________________ Circle the word that best describes the frequency of such behaviors: **Note- Always= More than twice a week; Often= Once a week; Sometimes= Once every 2-4 weeks; Rarely= Once every 2-4 months, or has done it in the past* Try to run away Always Often Sometimes Rarely Never

Try to hurt caregiver by biting, hitting, kicking, or

other harmful action Always Often Sometimes Rarely Never

Try to hurt other children by biting, kicking, hitting or other harmful action

Always Often Sometimes Rarely Never

Withdraw Always Often Sometimes Rarely Never Tantrum Always Often Sometimes Rarely Never

Refuse to cooperate Always Often Sometimes Rarely Never Becomes silly or

inappropriate Always Often Sometimes Rarely Never

Throw or break things Always Often Sometimes Rarely Never Attention seeking

behaviors Always Often Sometimes Rarely Never

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Page 8: Family Treatment Centre Prince Albert Parkland … ACASTSP...2014/11/03  · Family Treatment Centre Prince Albert Parkland Health Region 1200-24th Street West Prince Albert, Sask.

Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

Client Checklist of what to bring: Alcohol Free personal hygiene products (shampoo, soap, toothbrush, etc) Feminine products (tampons, pads) Six weeks of prescribed medication (to be turned in at intake) Six weeks of methadone prescription when applicable Long distance calling card (if applicable) Spending Money Alarm clock Laundry soap for 6 weeks Mom’s Checklist of what to bring: Diapers, pull-ups and baby wipes Your child’s favorite toys (Maximum of 3) Mother and child identification (Hospitalization Cards) What not to bring: Cell phones, MP# players, I-pods, laptops, I-pads, etc Movies/ DVD’s Personal gaming devices Valuables Provocative/ inappropriate clothing or reading materials Perfumes NOTE: Belongings will be searched upon arrival and all unsafe products will be removed.

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

Family Treatment Centre- Prince Albert Parkland Health Region Consent Form

Name: D.O.B: HSN: I voluntarily consent to the exchange of verbal and written information concerning my condition and the services I received, for the purpose of my recovery and treatment, between PAPHR Family Treatment Centre and the following individuals and/or organizations:

Organization Name & Telephone Email Additions/ Date/Sign

Review date & Initial

Addiction Services Outpatients Clinic

Indian Child and Family Services

Social Services- Child protection

Methadone Clinic

Physiatrist

Psychiatry

Family Physician

Mental health services

Social Services- Financial

School

Place of Employment

Early Childhood Intervention

Children’s daycare

Native Coord .Council - NCC

Pharmacy

Probation Officer

Parole Officer

Family-specific

(Please initial any/and all additions to this form)

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

I understand the information regarding my case will be held in the strictest of confidence and may/will be disclosed to other parties only with my consent or under the following circumstances: (1) Information pertaining to my case may be shared with other members of the care team only when necessary to carry out my service plan; (2) If records are subpoenaed the program is legally required to release information; (3) If I pose a threat to myself or others, confidentiality may be broken in order to prevent harm. I understand that I can withdraw consent from any individual or organization. At any point in time, I can withdraw from the services provided by the Family Treatment Centre thus making this Consent Form invalid. It is understood that the information obtained by the Family Treatment Centre will not be shared with any party other than those indicated on this form. Client Signature Date The meaning and scope of this consent form has been explained to the client and/or the legal guardian. The client and/or legal guardian has acknowledged that the intent was understood. Staff Signature Date

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

PHYSICAL 

EXAMINATION 

NAME:___________________________________ 

PHN:____________________________________ 

 DOB:____________________________________   

  Return to: Family Treatment Centre                     1200 24th St West                     Prince Albert, SK S6V 5T4 Phone:       306‐765‐6375 Fax:            306‐765‐4670 

        

 

 Vital Signs

Medication(include OTC drugs):_______________________________________________________________________ _________________________________________________________________________________________________ Allergies (describe reaction___________________________________________________________________________ __________________________________________________________________________________________________ Past Medical History:________________________________________________________________________________ __________________________________________________________________________________________________ Social History – Current Occupation:_______________________ Smoking:_____________ Alcohol _________________ 

BP___________  HR___________  Resp_________  Ht___________  Wt__________  Temp_________ 

  Normal  Abnormal  Not assessed  Specify Abnormalities 

Skin         

Head         

Eyes‐General         

Eyes‐Fundoscopy         

Ear & Nose         

Mouth         

Neck         

Cardiovascular         

Respiratory*(Thorax)         

Abdomen         

Lymphnodes         

Extremities         

CNS‐Gait         

Level of Consciousness         

Cranial Nerves         

Neuro ‐ Reflexes         

Motor & Sensory         

Breast/Genital/Rectal         

Routine Pre‐ Admission Lab Work   CBC F.B.S (spot okay) Liver Function Test HBSAG/B/C Routing Urinalysis Forward Results to: Family Treatment Centre 1200 24th St West Prince Albert, SK S6V 5T4 

Diagnosis and Proposed Management: ___________________________________________ ___________________________________________ Physician Signature ___________________________________________ Date:_________________________ 

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

PROVINCIAL PRIMARY ASSESSMENT INTERVIEW QUESTIONS 

 REASON FOR REFERRAL:   

If the client has been referred from another source, any relevant information for the referral agent can be documented her (e.g., probation, other health profession etc)      

 

 

 

CLIENT AND FAMILY PERSPECTIVE: 

Is there anything that you see as stressful in your life? Such as stressful events (finances, loss/grief, concern for others, traumatic events, family responsibilities, parenting, separation/divorce, moves) 

 

 

 

BACKGROUND INFORMATION 

1.  Developmental History (issues during pregnancy such as addictions; delivery; developmental 

milestones; temperament; separations, family of origin) 

 

 

 

2. Physical Health History 

Are you or anyone in your family experiencing significant health concerns? 

 

 

 

                                                                                                                            

o Relevant Medical conditions, chronic conditions, surgical history, 

 

 

 o Communicable diseases?   

 

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

 

3. Educational/Occupational Status & History 

Have you ever skipped school to get high?  Were you ever suspended, if so why? 

 

 

 4. Family Functioning and Relationships 

Dynamics:  How do you communicate in your family, resolve conflict? 

 

 

 

  Is there someone in your family you are particularly close to?   

 

 

 

 

  Elaborate on your supports   

 

 

 

  How do you get along with others in your family or in other relationships? 

 

 

 

 5. Financial    

Source of Income    

 

 

 Children/Youth 

What do you do when you need money?   

 

 

 

  Do you receive allowance? 

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

 

  Are there activities you would like to be involved in but can’t due to the cost? 

 

 

 

 6. Spirituality/Cultural Practices and Needs 

Would you like to share your current spiritual and cultural practices? 

 

 

 

 7. Social Involvement/Activities 

What recreational activities do you participate in?  (e.g. sports, volunteering, church 

groups, clubs, hobbies, other interests)  How does substance use fit in with socializing? 

 

 

 

  When did you last participate in the activities you enjoy? 

 

 

 

  Has substance use affected the activities you once participated in? 

 

 

 

 8. Personal and Family Psychiatric History 

Are you seeing a psychiatrist, mental health or addictions professional? 

Who? 

 

 

  How long have you been seeing them? 

 

 

 

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

Do you have a diagnosis?  (Who made the diagnosis and when?) 

 

  Have they prescribed meds? 

 

 

 

  Are you on any medications? 

 

 

 

  Have any of your family had mental health issues? 

 

 

 

  Are there any other feelings or thoughts affecting your life right now? 

 

 

 

 

 

  How are you coping? 

 

 

 

 

 

  Do you have any concerns about feeling depressed or anxious right now? 

 

 

 

 

  Is anyone else affected by your problems? 

 

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

 

 

 

 9. Danger to Self/Others 

Suicidal thoughts/behaviors 

All clients must be screened and where appropriate assessed for suicidal thoughts and behaviors.  A hierarchy of questions below, which gently leads to asking about suicidal ideas, is a generally accepted procedure for all health care professionals.  These questions may have to be asked in a different manner with younger or cognitively challenged populations.  

1.  Are you having any feelings of hopelessness, helplessness or depression? 

 

 

 

 

 

 2.  Have you had any thoughts, urges or behaviors related to harming yourself? 

 

 

 3.  Have you recently engaged in any reckless behavior such as; abusing alcohol or drugs, 

reckless driving or impulsive actions? 

 

 

 

 4.  Have things been so bad lately that you have thought you would rather not be here? 

 

 

 

 5.  Are you thinking of suicide? 

 

 

 

 6.  Have you made any current plans? 

 

 

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

 

 7.  Do you have the means to act on your plan? 

 

 

 

  Do you (or anyone in your family), currently engage in high risk behaviours? 

 

 

  Deliberate self harm (e.g. cutting, burning) 

 

 

  Have you ever been aggressive toward others? 

              (thoughts, intimidation, violence) 

 

 

 

 10. Substance Use, Problem Gambling and other Problem Behaviours 

Have alcohol, drugs (prescription or non‐prescription), gambling, tobacco ever been a 

concern for you or anyone in your family? 

 

 

 

 

  Can you tell me about your use (or the use of others in your family)? 

 

 

 

  

Can you tell me what your (their) drug of choice is? 

 

 

 

 

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

 

How often do you (they) use it? 

 

 

 

  What happens when you (they) use it? 

 

 

 

 

  Has anyone ever told you that you have a problem with alcohol? 

 

 

 

  Has anyone ever told you that you have a problem with drugs? 

 

 

 

  Do you (or anyone in your family) feel you need to cut down on your 

drinking/drug/gambling? 

 

 

 

 

  Do you (or anyone in your family) ever get angry when others comment on your 

drinking/drug/gambling? 

 

 

 

  Do you (or anyone in your family) ever have an eye opener (drink/drugs) to settle your 

nerves in the morning? 

 

 

 

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

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Do you (or anyone in your family) have a problem with gambling?  Or has someone said 

you have a problem with gambling? 

 

 

 

  Are you affected by other people’s problem behaviors? 

 

 

 

  Other behavioral problems such as pornography, internet, food, sexual promiscuity, 

shopping, gaming? 

 

 

 11. Legal 

Convictions? 

 

 

 

  Are you on probation/parole? 

 

 

 

  Any legal history related to substance use, gambling or mental health issues? 

 

 

 

 12. Motivation/Resiliency/Protective Factors 

Share a personal and/or family strength 

 

 

 

  Do you think there are benefits to making a change? 

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

 

 

 

  What do you hope to get from being here? 

 

 

  What would success look like? 

 

 

 

  What supports do you have?  (e.g. stable/secure housing, income security, positive role 

models, community recreation/involvement) 

 

 

 

 Client/Family Goals 

Have a collaborative discussion regarding goals and treatment options (consider barriers, strengths) 

How would you rank or prioritize goals? 

 

 

 

  Is there anything else you’d like to talk about? 

 

 

 

  Is there anything we haven’t addressed? 

 

 

 

  

Clinical Impressions/Conceptualization 

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

Summarize, observation based on facts presented.  (comment on appearance, behavior 

and cognition) 

 

 

 

  Identify the client’s (and/or the family’s) transtheoretical stage of change in relation to 

each area of difficulty (SMRS:  Transition, Stabilization/Adolescent Motivational Assess/ 

process (AMAP):  pre‐contemplation, contemplation, etc.) 

  

  Sources of external motivators 

 

 

 

  Note the diagnosis arrived at (in accordance with scope of practice of diagnostician) 

 

 

 

  Include alerts if any present (health risks, safety risks, pregnancy) 

 

 

 

 Baseline Measures 

( 25 Questions, AAIS, CAST, SASSI) 

 

 

 

  DIAGNOSIS 

 

 

  CAFAS 

 

 

21 Revised May 3, 2013

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

 

CDOI 

 

  Referrals 

 

 

  Timeframe for treatment and reassessment 

 

 

 

22 Revised May 3, 2013

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Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

Alcohol / Drug History Pattern

DRUGS First Used

Regular Use

How Often

How Much

Last Used

How Much

Increased Tolerance

Cigarettes

Alcohol

Marijuana

Cocaine

Ecstasy

Drug of Choice __________ Drug Most Often Used _____________ Symptoms Experienced Alcohol Marijuana Other

blackouts (lapse of memory) _______ ______ ______ loss of Control (inability to stop) _______ ______ ______ guilt (due to use or behavior while using) _______ ______ ______ use in the morning _______ ______ ______ hopelessness/helplessness _______ ______ ______ loss of motivation _______ ______ ______ short- term memory loss _______ ______ ______ paranoia _______ ______ ______ other ____________________ _______ ______ ______ attempts at controlled use

(amount, chemical, circumstances) _______ ______ ______ attempts at abstinence _______ ______ ______

23 Revised May 3, 2013

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24 Revised May 3, 2013

Family Treatment Centre Prince Albert Parkland Health Region

1200-24th Street West Prince Albert, Sask. S6V 5T4

Ph: 1 (306)765-6375 Fax: 1(306)763-4670

If “YES”, abstinence lasted about _________________________________________ Reason for abstaining __________________________________________________ Symptoms experienced due to abstinence NOTES

shakes _______ seizures _______ ____________________ sleeplessness _______ irritability _______ ____________________ nausea _______ hallucinations _______ ____________________ sweating _______ depression _______ ____________________ headaches _______ other _______ ____________________