YOUTH EMPOWERMENT SOCIETY SPECIALIZED YOUTH DETOX RE-ENTRY SURVEY

GENDER: _____ AGE: _____

1. How many times have you been in the Specialized Youth Detox Program?

One Time Two Times Three Times or More Dont Remember



2. Is this referral to Specialized Youth Detox Program and Ashgrove Detox the result of

Relapse Addiction to a Same Issue-
Different Substance I never quit using

3. If you relapsed what contributed to you using again?
___________________________________________________________________________
_________________________________________________________________________

4. Do you remember where you discharged to last time you left SYD?
___________________________________________________________________________
_________________________________________________________________________


5. How would you rate your physical health now, compared to the last time you accessed the
SYD program or Ashgrove?

Better Worse About the Same Dont Remember

6. How would you rate your emotional/mental health now, compared to the last time you
accessed the SYD program or Ashgrove?

Better Worse About the Same Dont Remember

7. What types of things (if any) did you try to do so you wouldnt use again?
___________________________________________________________________________
_________________________________________________________________________

8. What are your goals/plans while you are at Youth Detox?
___________________________________________________________________________
_________________________________________________________________________

9. What types of things can we do to help you meet your goals?

________________________________________________________________________________
_________________________________________________________________________
SYD Discharge Summary ___________________________________________SYD File #:______
Youth Name: _________________________________________ Referral Date: __________________________
Date of Admission: ____________________________________ Date of Discharge: ______________________
Length of SYD Service: _____________________________Days Length in Ashgrove: ________________Days
Referral Agent: ___________________________________________________________________________________
Consent to Release Info to Referral Agent: YES NO
Prescribed Withdrawal Medication: YES NO
If Yes, describe:
___________________________________________________________________________________________________
___________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Completed 7-10 days: YES NO Completed Personal Goal: YES NO Goal Days: ________
Reason for Admission:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________________________________________________________
Reason for Discharge:
_________________________________________________________________________________________________
__________________________________________________________________________________________________
________________________________________________________________________________________________
Goals:
_________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_____________________________________________________________________________________________
Progress:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________

Youth Empowerment Society SYD Discharge Summary pg. 2______
Progress continued:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________
Condition at Discharge:
________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_____________________________________________________________________________________________
Recommended Action:
_________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________________________________________________________
Follow Up Required:
________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________________________________________________________
Family Engagement: Yes No
Met with Mental Health and Addiction Services Staff: Yes No Who: __________________________________
ICM/Discharge Meeting: Yes No Who attended:_______________________________________________________
__________________________________________________________________________________________________
________________________________________________________________________________________________
Staff Completing Form: ______________________________________________Date: _________________________
Case Manager: _____________________________________________________________________________________
Youth Empowerment Society SYD Discharge Summary pg. 3______
Name: File Number:
Referrals
Referred to: Date:





















Funded By:
Ministryfor Children andFamily
Development, Vancouver Island Health
Authority, United Way,
Cityof Victoria, BCGaming
Commission, BusinessCommunity
PrivateDonations, VariousGrants,
Individual Donors, FundraisingEvents
Youth Empowerment Society
YES Office
533 Yates Street
Victoria, BC V8W 1K7
Phone: (250) 383-3514
Fax: (250) 383-3812
E-Mail: vyes@ultranet.ca
Mental Health Addictions
Services
Sexually Exploited Youth
Liaison Program
Youth Outreach Teams
Summer Opportunities
Program
Life Skills
Volunteer Program
General Services

KEYS - Kiwanis
Emergency Youth Shelter
2117 Vancouver Street
Victoria, BC V8T 3Z9
Phone: (250) 386-8282
Fax: (250) 384-0778
E-Mail: keys@vyes.ca

THE CLUB - Alliance Club
533 Yates Street
Victoria, BC V8W 1K7
Phone: (250) 361-3923
Youth Phone: (250) 382-7553

Mental Health Addictions
Services

SYD - Specialized Youth
Detox
Office Phone: (250) 383-3514
Fax: (250) 383-3812
E-Mail: syd@vyes.ca
Ashgrove: (250) 383-3582

GOALS - Getting off Alcohol
& Substances
Phone: (250) 386-8282
Fax: (250) 384-0778
E-Mail: goals@vyes.ca

ACCESS School
533 Yates Street
Victoria, BC V8W 1K7
Phone: (250) 380-6483
Victoria

SYD Residential Child Care Consent

Consent to Administer Medication
As legal guardian, I/we hereby give SYD staff permission to administer medication prescribed by a
physician to _______________, with the understanding that we will be notified of medication
changes.

I/we also give permission to the SYD staff to administer over-the-counter type medication, such as:
Tylenol, Advil, Pepto Bismol, Ambesol, cough suppressants, Polysporin etc., if requested by
______________, and approved by the pharmacy.

____________________________________ ______________________
Signature of Parent or Legal Guardian Date


Consent to Contact Emergency Services or Seek Medical Attention
In case of illness or accident of ______________________________, and I/we cannot be reached by
phone, I hereby authorize the staff of Specialized Youth Detox to seek medical attention by his/her
family doctor or to call an ambulance. All costs incurred are the responsibility of the parent or legal
guardian.

____________________________________ _______________________
Signature of Parent or Legal Guardian Date


Consent to Participate in Supervised Physical Activities
As legal guardian, I/we hereby give permission for ______________________ to participate, if he or
she chooses, in supervised physical activities such as aerobics, weight-lifting, swimming, skating, or
jogging.

____________________________________ _______________________
Signature of Parent or Legal Guardian Date


Comments: _____________________________________________________________________
________________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________


Funded By:
Ministryfor Children andFamily
Development, Vancouver Island Health
Authority, United Way,
Cityof Victoria, BCGaming
Commission, BusinessCommunity
PrivateDonations, VariousGrants,
Individual Donors, FundraisingEvents
Youth Empowerment Society
YES Office
533 Yates Street
Victoria, BC V8W 1K7
Phone: (250) 383-3514
Fax: (250) 383-3812
E-Mail: vyes@ultranet.ca
Mental Health Addictions
Services
Sexually Exploited Youth
Liaison Program
Youth Outreach Teams
Summer Opportunities
Program
Life Skills
Volunteer Program
General Services

KEYS - Kiwanis
Emergency Youth Shelter
2117 Vancouver Street
Victoria, BC V8T 3Z9
Phone: (250) 386-8282
Fax: (250) 384-0778
E-Mail: keys@vyes.ca

THE CLUB - Alliance Club
533 Yates Street
Victoria, BC V8W 1K7
Phone: (250) 361-3923
Youth Phone: (250) 382-7553

Mental Health Addictions
Services

SYD - Specialized Youth
Detox
Office Phone: (250) 383-3514
Fax: (250) 383-3812
E-Mail: syd@vyes.ca
Ashgrove: (250) 383-3582

GOALS - Getting off Alcohol
& Substances
Phone: (250) 386-8282
Fax: (250) 384-0778
E-Mail: goals@vyes.ca

ACCESS School
533 Yates Street
Victoria, BC V8W 1K7
Phone: (250) 380-6483
Victoria
SYD Residential Child Care Consent

Consent to Release Youth to the Following Individual(s):































As legal guardian, I/we hereby give permission for ____________________ to be
released to the following individuals:

Name Date Consent
Given
Staff
Initials
















































________________________________ _______________
Signature of Parent or Legal Guardian Date

VICTORIA YOUTH EMPOWERMENT SOCIETY

CLIENT CONFIDENTIALITY AND INFORMED CONSENT FORM

Welcome to the Victoria Youth Empowerment Society (YES). Our services are voluntary and confidential. All
Counsellors take seriously the need to safeguard the privacy and confidentially of all personal information that you
provide to us. We will not release any information about you or your family to anyone unless you sign a release.
However, there are 4 limitations to confidentiality:

4 LIMITATIONS TO CONFIDENTIALITY:

1) IN A CASE WHERE CHILD ABUSE OR NEGLECT, INCLUDING SEXUAL ASSUALT, IS REPORTED THE
COUNSELLOR MUST BY LAW CONTACT THE MINISTRY OF CHILDREN AND FAMILY DEVELOPMENT.
2) WHEN A YOUTH STATES THEY INTEND TO HURT THEMSELVES OR COMMIT SUICIDE, STAFF HAVE A DUTY TO
INVOLVE NECESSARY EMERGENCY SERVICES.
3) WHEN A YOUTH STATES THAT THEY INTEND TO HURT ANOTHER PERSON OR THEIR ACTIONS OR KNOWLEDGE
MAY POTENTIALLY HARM OTHERS, STAFF HAVE A DUTY TO NOTIFY THE APPROPRIATE POLICE AUTHORITY.
4) BY LAW UPON SUBPOENA, TO TESTIFY IN COURT AT THE DISCRETION OF A JUDGE.

Youth File:
As Counsellors, we need to maintain files of our involvement together.
We keep a paper file for the forms we fill out. These are securely maintained in a locked cabinet behind a
locked door.
Information regarding individual plans, goals, transition plan, etc. will be printed and placed in your file.
We also maintain your file on a secure database system. The purpose of this database is so that we can
evaluate what best practices work. Only yourself, YES counsellors, and their supervisors see your file.
I understand that I have access to my client file, including written and electronic information through a
request made to Victoria Youth Empowerment Society to view the files. I also have access through the
Freedom of Information and Protection of Privacy Act. We cannot give you access to material on your file
that is written by somebody other than YES counsellors, information that is about someone other than
yourself, or information that may identify the privacy of another person
Our program uses a team approach model in helping you work towards choices for growth and change.
This means that your Counsellor receives support, feedback and follow-up from other members of the team
including; Specialized Youth Detox, the Lifeskills Program, the Youth Services Outreach Team, the Youth
and Family Counsellors, Kiwanis Emergency Youth Shelter, the Mental Health Liaison, the Alliance Club, the
Supported Independent Living Program and the Youth Clinic.


I have read (or had read to me) and understand the confidentiality of services agreement

________________________ __________________________ ________
Youths signature Counsellors signature Date


I have been informed of the services provided through Victoria Youth Empowerment Society and consent to
these services. My consent is valid for one (1) year from the date below.

________________________ __________________________ ________
Youths signature Counsellors signature Date








VICTORIA YOUTH EMPOWERMENT SOCIETY


CLIENT CONSENT FOR RELEASE OF INFORMATION


I, __________________________, give permission to the counsellors at Victoria Youth
(youths name)
Empowerment Society to release and/or receive information from the following people/agencies.


Start
Date

Agency/Person/
Relationship

Phone
Number
Content of
Information/
Purpose
Expiry
Date
(not to
exceed 3
months)
Youths
Signature



Youth Empowerment
Society -YES
All
Support
Referrals
Case Planning





VIHA
All
Licensing
Requirements





Youth and Family
Substance Use Services
YFSUS
Referral
Information
Case Planning





Victoria Youth Clinic
Downtown Medical Clinic


Follow Up to Med
Screen

















I understanding my consent expires on the date stated above or the date I stop receiving services

from the Agency, whichever is first. ___________________
(initial)

I understand that I can withdraw my consent at any time, for any reason __________________
(initial)

Youths Signature: ______________________________________ Date:_____________________


Counsellors Signature: __________________________________ Date:_____________________


VICTORIA YOUTH EMPOWERMENT SOCIETY


CLIENT CONSENT FOR RELEASE OF INFORMATION


I, __________________________, give permission to the counsellors at Victoria Youth
(youths name)

Empowerment Society to release and/or receive information from the following people/agencies.


Start
Date

Agency/Person/
Relationship
Phone Number
Content of
Information
Purpose
Expiry
Date
(not to
exceed 3
months)
Youths
Signature




































I understanding my consent expires on the date stated above or the date I stop receiving services

from the Agency, whichever is first. ___________________
(initial)

I understand that I can withdraw my consent at any time, for any reason __________________
(initial)

Youths Signature: ______________________________________ Date:_____________________


Counsellors Signature: __________________________________ Date:_____________________



August 2011




Youths Approved Phone List














































DATE

NAME

RELATIONSHIP

PHONE
NUMBER

CONSENT GIVEN
BY
PARENT/GUARDIAN

Yes/No Staff Initial


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No
SPECIALIZED YOUTH DETOX YOUTH GUIDELINES
SMOKING: Smoking is not permitted in the house! Youth can keep cigarettes in their possession.
Lighters and matches are always in the possession of staff. Staff will be monitoring youths cigarette
intake, and will have a discussion around this matter with youth if it appears to be an issue. Youth are
allowed to lend or give out cigarettes but are NOT allowed to share cigarettes, due to Health and
Safety concerns. Only one youth can be outside smoking at a time. Other youth can be outside with
staff supervision if an activity is taking place. All smoking must take place in the gazebo. The last
cigarette is to be completed by 10:30pm. If smoking guidelines are not followed, consequences will
result in chores and possible discharge.
MEDICATIONS: Medications are dispensed by staff and according to doctors orders. Over the counter
medications are available (Tylenol, Advil) but we do suggest alternative methods (drinking water and
tea, taking a bath, lying down) before administering them. Non-withdrawal meds are returned upon
discharge; withdrawal medication will be not returned.
PHONE: Staff dial out all phone calls and ask for the person before giving the phone to the youth. All
phone calls are monitored by staff. During the first 4 days youth can only make phone calls to family
and support workers. On day 5 youth can begin adding supportive/positive/non-using friends to their
phone list with approval from the youths legal guardian. If phone calls are not appropriate or
triggering, staff will ask youth to end the call. Last phone call is to be completed by 10pm.
OFFICE: Youth cannot enter the office without permission; youth need to knock and wait outside the
office before entering. This is due to confidentiality matters concerning files. When the office door is
shut please wait to speak to staff unless it is an emergency. Please allow staff to complete shift change,
i.e. waiting to ask for the lighter or making phone calls.
ROOMS/FOOD: Your bedroom is your own personal space. Youth cannot go into each others rooms.
Staff complete bedroom checks at night time. Food is not to be eaten in the youths rooms due to
health and safety issues. Staff prepares all meals at SYD; there is a snack drawer that you can help
yourself to. All eating should be done at the kitchen table there is to be no food in the living
room/craft room.
MUSIC: The music level on the stereo/TV is at the discretion of each staff on shift. This will vary due to
programming and house dynamics. Stereos are not permitted in the youths rooms; youth are allowed
to bring mp3 players into rooms. SYD is not held responsible for any damaged/stolen or missing
electronics or belongings bring in these items at your own discretion. Any devices with WiFi
capabilities are not permitted at SYD.
BEDTIME: At 10:30pm the TV in the living room is shut off and youth are to start getting ready for bed.
Youth are to be in their rooms by 11pm. Youth can still spend time downstairs in the living room or the
kitchen until 11pm; however, everything that needs to be completed for bedtime must be done so that
youth are ready to be in their rooms for 11pm. Youth do not need to go to sleep at 11:00; they can be
awake in their rooms. After day 3 youth will be woken up at 9:30 as we go to the gym in the mornings
after breakfast. This is also in order to get the youth back on a regular sleep/awake schedule.
SUPERVISION: SYD is a monitored program; staff will be around at all times. Youth need to inform staff
if they wish to go in the backyard or downstairs to the craft room. If more than two youth are
downstairs a staff member needs to be present. Bed checks are done at night time on a regular basis.
The windows and doors in the house are chimed; tampering with the alarm system is grounds for
discharge. There is no roughhousing, play fighting, or touching between youth.
RESPECT: SYD runs on a policy of respect. This means youth are expected to respect other residents,
staff, and property. This also means that excessive swearing and derogatory language is not permitted,
as well as derogatory music or videos. We also need to respect our neighbours and their property; this
includes not going over the fence to retrieve sports equipment, and not swearing excessively while
outside.
DRESS CODE: Youth are expected to dress appropriately while at SYD. If youth wish to sun tan in the
backyard both male and female youth must be wearing tank tops and shorts. Shorts are to cover the
length of their pockets. No bathing suits or sports bras will be allowed to be worn while outside. Youth
should not be wearing extremely short shorts, exposing midriff, or cleavage. No inappropriate logos
are permitted. If youth require clothing there is a variety of clothes to choose from in the basement.
PROGRAMMING: SYD has daily programming. This programming is based on the words of the day
which are posted on the staff office door. Programming is a part of being at SYD and participation is
expected. If youth do not want to participate in programming they will need to be in their rooms
during this time. Other than for the reason of not feeling well, you should be participating in
programming. Programming includes a daily recreation outing in the morning (10:30am-11:30am), a
group based on the word of the day (3:30pm-4:30pm), and reflection time (7pm-8pm). Reflection time
occurs after dinner; during this time youth are given an activity to complete or can journal. As a part of
programming, youth are also required to meet with an A&D counsellor if youth do not have an A&D
counsellor they will be connected with one. In order for the withdrawal management counsellors at
SYD to set up a discharge plan for youth, youth will be meeting with their case manager at least three
times throughout their stay.
PROGRESS FORMS: Staff will ask youth to complete a progress form following breakfast. This allows
staff to monitor their withdrawal and check on the youths general well-being.
OUTINGS: Youth are allowed to go on outings with family members and support workers. Youth do not
go on outings on day one. The guidelines for going on outings with parents and support workers
include no contact with friends via phone or email, supervision at all times, and a belongings search
upon returning to SYD. These outings can be approximately 1 to 2 hours; exceptions can be made
around holidays or special events. While on outings with staff, youth need to be respectful of the
community. This involves not swearing or acting inappropriately. Youth may not bum cigarettes from
people in the community while on outings. Youth are also not allowed to talk with friends that they
may see on outings, to respect the confidentiality of others in this program.



















Specialized Youth Detox (SYD) Youth Agreement

I, _____________________________, have been accepted into the Specialized Youth Detox program
(SYD) for the purpose of withdrawing from alcohol and/or drugs, with the objective of withdrawing from an
addiction to a substance(s). I agree to the following conditions:

1. I am accepting referral into SYD Emergency component to voluntarily withdraw from
_______________________________________________________________________.
2. I further understand that I can leave the program at any time. However if I leave the SYD program
prior to completing withdrawal, and without consultation/approval of my SYD Withdrawal
Management counsellor, I will be considered to be voluntarily discharging myself from the SYD
program.

The following are conditions for acceptance into my individualized withdrawal program:

1. I have been screened and assessed by a physician at the time of intake and deemed to have a health
status that does not require hospitalization. Name of Physician: ______________________.
2. I agree to the standard guidelines for residing in the SYD program as outlined during intake.
3. I agree to attend medical appointments as suggested by Withdrawal Management Counsellors.
4. I agree that my stay in detox is based on being 100% drug free (with the exception of prescriptions &
OTC medications deemed necessary from the monitoring physician).
5. I agree not to bring any drugs (not prescribed) or drug paraphernalia into the SYD program and I am
subject to searches of my room and belongings at the request of the Withdrawal Management
Counsellors. Any contraband found in the SYD program will result in automatic discharge from detox.
6. I agree that I will make no contact (by phone or otherwise) with anyone outside of my family and/or
support workers (unless prior approval received from Withdrawal Management Counsellors) for the first 96
hours (4 days) that I am in SYD. I further agree that all phone calls out of SYD will be dialled by the
Withdrawal Management Counsellors and that I will not make contact with any past associations that may
endanger the safety of myself, others or the program.
7. I agree to develop a plan for future treatment with my Withdrawal Management Counsellor prior to my
leaving the SYD program.
8. I agree that if I leave SYD prior to completion of my individualized withdrawal plan, that the program
staff will be contacting my legal guardian(s).

The terms of the agreement have been explained to me and I understand and am committed to the
process of recovery.

Signature of Youth_________________________________________Date:_________________

Signature of Witness_______________________________________Date:_________________


SYD YOUTH CASE PLAN



Name: File #:


Agrees to discuss meeting with A&D Counsellor

Agrees to participate in SYD Daily Programming Activities

Agrees to meet with their Case Manager to discuss post-detox plans

Agrees to participate in discharge meeting/ICM


Counsellor Signature: Date:

Youth Signature: Date:

PERSONAL PLAN FOR DETOX
Reconnect with Family/Caregivers
Connect with Support Workers
Address Housing needs post Detox
Explore Treatment Options
Connect with School
Connect with Community Resources (SIL, Counselling, etc.)
________________________________________________________________________
Address legal Issues/Probation
Address Medical Concerns
Explore Mental Health Conerns
Other:
___________________________________________________________________________
___________________________________________________________________________
________________________________________________________________________



Counsellor Signature: Date:

Youth Signature: Date:



Nutritional Care Plan

Name: Admission Date:
Age: SYD File #:
Pregnant: YES NO N/A Gender: M F T

Daily Youth will complete a continuing progress form that has the youth identify their appetite and
if they are experiencing gastrointestinal disturbances (nausea, vomiting, diarrhea). Staff will
record on the youths daily log meals consumed.
Dietary Restrictions (i.e. vegetarian or lactose intolerant):



Food Allergies:




Food Likes:


Food Dislikes:



Other Nutritional Concerns:


Youth Experiencing Nausea/Vomiting/Diarrhea:
Staff will monitor youth who are experiencing nausea/vomiting and/or diarrhea
If a youth is experiencing mild nausea/vomiting/diarrhea (upset stomach and vomiting/diarrhea
occasionally):
- ensure youth is receiving clear fluids such as: ginger ale, Gatorade
- Ensure youth is given a BRAT (bananas, rice, applesauce, toast) diet.
If a youth is experiencing severe vomiting or diarrhea (continuous vomiting or diarrhea over 3
hours) staff will seek medical attention for the youth

Pregnant Youth:
Youth will receive extra servings of protein and dairy daily
Youth will be encouraged to take prenatal vitamins containing folic acid




Name:






Date:
Age: SYD File #:

Oral Hygiene Care Plan

SYD will provide all youth with oral hygiene products such as: toothbrush, toothpaste and dental floss

If a youth is experiencing issues with their oral/dental health, SYD will ensure the youth receives access to Dental Health
Care or Medical Health Care as needed.



Counsellor Signature: Youth Signature:


Recreation and Leisure Care Plan

SYD will provide the youth with daily recreation and leisure activities. Youth will have the opportunity to participate in daily
recreation activities between 10:30am and 1:00pm. Youth will have to opportunity to engage in activities such as swimming,
skating, tennis and working out at the facilities at Oak Bay Recreation Centre. SYD also provides youth with the following
activities: arts and crafts, board games, books, video games, and movies. SYD staff will also when possible take the youth
on community outings such as accessing regional parks and beaches, museums, art galleries and community festivals.

Medical Screen Doctor has given permission for the
youth to participate in physical activities. (see
medical screen form)



YES


NO
Parent/Legal Guardian has given permission for the
youth to participate in physical activities. (see
residential child care consent)


YES


NO



Youths Preferred Recreational and Leisure Activities:








Counsellor Signature: Youth Signature:





Recreation Outing Ideas
Name: Date:

Please circle the outings of interest

Outdoors

Hikes

Mount Tolmie Mount Doug

Walks

Clover Point Willows Beach

Ogden Point
Fishermanss Warf Beacon Hill Park (Petting Zoo) Oak Bay Marina (Feeding Seals)

Games

Croquet Basketball

Baseball
Volleyball Boccee Ball Tennis

Indoors

Yoga Stretching Workout

Oak Bay Rec Centre: Swimming/Sauna/Hot tub/Skating etc.

Entertainment

Imax Museum Bug Zoo

Art Gallery
Craigdarroch Castle Hatley Castle Fort Rod Hill Fired Up! Ceramics



Specialized youth Detox (SYD) *Continuing Progress Form


DATE: __________________TIME OF DAY: ______________
NAME: _____________________________________________

Symptom Severity Checklist

Please circle one number in each category.

How do you feel about
being at detox?
0 Very happy
1 Happy
2 Okay
3 Not happy
MOOD
0 Cheerful
1 Sometimes low
2 Often Low
3 Very low
ANXIETY
0 Finds it easy to relax
1 Finds it hard to relax
2 Hardly ever relaxes
3 Cannot Relax


How do you feel about
where you are going (to
live) after detox?
0 Happy/secure
1 Unsure
2 Anxious
3 Scared


How much are you
benefiting from being at
detox?

0 A lot
1 Quite a bit
2 A little bit
3 Not much

SLEEP
0 Sleeps well
1 Broken sleep
2 Difficulty getting to sleep
3 Insomnia
Do you feel like you can
talk to staff at SYD if you
need to?
0 Yes
1 Most of the time
2 Sometimes
3 Not really

APPETITE
0 Good appetite
1 Fair appetite
2 Poor appetite
3 No appetite

SWEATING
0 No sweating
1 Sweating
2 Moderate sweating
3 Profuse sweating
Upset stomach
0 Normal
1 Mild nausea (stomach
ache)
2 Persistent nausea
3 Vomiting, two or more
times
Shakes
0 None
1 Slight
2 Moderate
3 Lots
COMMITMENT TO DETOX
0 Strong
1 Moderate
2 Slight
3 None



Completed By: _______________________________


Comments:


SYD Youth Discharge Agreement
Name: File Number:

Date:

SYD is a voluntary setting, and you are able to discharge from the resource if you choose to do so. This
contract is put in place in order to ensure your safety when leaving SYD. In the event of an unplanned
discharge you agree to the following conditions:

Voluntary Self-Discharge:
I, _____________________________ will wait until an appropriate time of day to discharge
(i.e. during the day not late at night)
I, ______________________________will wait for an appropriate and supportive adult to transport
me home, or to a safe alternate accommodation
If the above options are not possible I, _________________________ will accept a referral to a
suitable emergency shelter in this community


Staff Directed Discharge:
I, ______________________ will wait for an appropriate and supportive adult to transport me home
or to a safe alternate accommodation as long as staff deem it safe to do so
I, ______________________ will accept a referral to a suitable emergency shelter in the community
and will leave SYD without confrontation.


SYD staff will attempt to make all possible considerations for client safety in the event of an unplanned
discharge. Youth should be aware that SYD staff will immediately contact legal guardians, caregivers,
and if appropriate emergency services in the event of any youth discharge from the program.




Client Signature SYD Staff Signature
















YOUTH EMPOWERMENT SOCIETY SYD YOUTH INFORMATION SHEET___

Intake Date:______________________ SYD File Number:________________________
Youth Name: _____________________________________________________________________________________
Address: ________________________________________________________________________________________
Phone Number: ___________________________________________________________________________________

PHN: ______ DOB: _____ AGE: ________ GENDER:
HEIGHT: ______ WEIGHT: _____________HAIR: _____________EYES: _____________
OTHER IDENTIFYING FEATURES:
ALLERGIES: _______OTHER MEDICAL CONCERNS:
WITHDRAWING FROM: _____________________________________METHODS OF USE: _______

Legal Guardian Contact Information
Name: ___________________________________________________________________________________________
Relationship to youth: _____________________________________________________________________________
Address: ________________________________________________________________________________________
Phone Number: ___________________________________________________________________________________

Emergency Contact Information
Name: ___________________________________________________________________________________________
Relationship to youth: _____________________________________________________________________________
Address: ________________________________________________________________________________________
Phone Number: ___________________________________________________________________________________

Primary Care Physician: ____________________________________Phone Number:__________________________

Other Medical Practitioners involved (Mental Health workers/psychiatrists, etc.):
________________________________________________________Phone Number:___________________________
________________________________________________________Phone Number:___________________________

MEDICATIONS PRESCRIBED FOR WITHDRAWAL (INCLUDE DOSAGE AND TIME):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
MEDICATIONS NOT FOR WITHDRAWAL(INCLUDE DOSAGE AND TIME):
_________________________________________________________________________________________________
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