Intake and Initial Assessment

Youth and Family Addiction Services

SYD File Number:
Initial Contact: Date: Time:
Intake Counsellor: Date/s: Time/s:
Limits o Conidentiality e!"lained and a#reed to: Notes:
A$ %asic Demo#ra"hics
Name:
Female Trans#ender

&ale
Date o %irth:
(day/month/year)
Address: 'hone:
() to leave messa#e
Cell 'hone:
() to leave messa#e
Name o Family Doctor i a""licable: Contact inormation i available:
Care Card *:
Name o +uardian: Contact 'hone Number:
,mer#ency Contact Name: ,mer#ency Contact 'hone Numbers:
Are you attendin# school-
Yes No +rade ......... School ...................
Youth/s hair colour ,ye colour 0ei#ht 1ei#ht Distin#uishin# Features
Formal 2eerral Sources:
Self School Physician MCFD Youth
Justice e.g. POs
Youth
Forensics
MCFD CYF
Mental
ealth
Parent/Caregi!er Foster Parent MCFD Child
Protection
Formal 2eerral Sources 3 4I0A 'ro#ram/Service
"#$ Youth % Family $ddiction Ser!ices (contracted/direct ser!ice)
"#$ $dult Mental ealth
"#$ $dult $ddiction Ser!ices
"#$ Child Youth Family Mental ealth (ty&e e.g. Jac' (edger ouse)
"#$ Mental ealth (other)
"#$ Pu)lic ealth (e.g. Youth Clinic)
(ther Formal 4I0A 2eerrals 5not listed in *67:
Name 'ro#ram/Service
(ther Formal 2eerral Sources 3 Community Service5s7:
Name 'ro#ram/Service
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Contact Name rom 2eerrin# A#ency: 2eerrin# 'erson/A#ency 'hone Number:
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%$ 'resentin# Issues:
Please se !or conselling skills to engage t"e referral agent or client in a con#ersation a$ot t"e im%act of isses on t"e client&s life'
Name o "erson #ivin# inormation: 2elationshi" to youn# "erson:
8$ a7 Are you here or yoursel- or are you concerned about someone else-
8$ b7 Are you here because someone 9ants you to be- Yes No
1ho-
:$ 1hat are some o the concerns or issues that have brou#ht you here-
6$ 1hat dru#s; includin# alcohol are involved-
8
st
: 2oute: Fre<uency: A#e o 8
st
use:
:
nd
: 2oute: Fre<uency: A#e o 8
st
use:
6
rd
: 2oute: Fre<uency: A#e o 8
st
use:
=$ 1hat made you look or su""ort at this time-
>$ 1hat are you doin# no9 that is hel"in# you to mana#e the situation-
?$ 1hat are you ho"in# to #et out o this "ro#ram-
@$ Is there anythin# that you need that 9ill hel" you to come to this service- For e!am"le:
(next appointment - where, when, reminders, timing of appointments, someone coming with you, transportation,
location, disability/other access needs, literacy)
A$ Is there anythin# that 9ould #et in the 9ay o comin# to this service-
B$ a7 Are there any other "eo"le or services 9orkin# 9ith you-
B$ b7 1ho else 9ould you like involved-
B$ c7 Do you have any current involvement 9ith the le#al system- Yes No
Are you on "robation Yes No
Did someone tell you that you have to be here- 5Le#ally mandated7 Yes No
Additional inormation:
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Name o 'robation (ice 'robation (icer 'hone Number:
C$ Immediate Youth32elated 2isks:
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8C$ Do you/they have any current or historical medical concerns- 5e$#$ asthma; seiDures7$
Yes No Describe :
88$ Do you/they have any aller#ies-
Yes No Describe :
8:$ Are immuniDations u" to date- 52esidential Services (nly7 Yes No Describe:
86$ Do you/they re<uire 9ithdra9al mana#ement services-
Yes No
8=$ I EyesF to <uestion * 86; could you/they be "re#nant-
Yes No
8>$ 0ave you/they been dia#nosed 9ith a mental health concern-
Yes No %y 9hom- Indicate 'rimary Dia#nosis:
8?$ Do you "ersonally have any concerns about your/their emotional and mental health- Yes No
Additional Inormation:
8@$ Are you/they thinkin# about suicide-
(If yes, complete suicide assessment with client
immediately.)
Yes No
8A$ Are you/they thinkin# o hurtin# someone
else-
(If yes, find out more details immediately.)
Yes No
Additional inormation on above: Additional inormation on above:
8B$ Are there any additional immediate risks to sel or others- Yes No
(e.g. not ta'ing medications* trou)le +ith others* self,harming )eha!iours)
'lease describe:
:C$ 0ave you/they seen a doctor 9ithin the last si! months- Yes No
N(T,: I ans9ers to <uestions 8C3:C raise concern 3 recommend youth see a "hysician
D$ The ollo9in# sections are rom client res"onses:
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:8$ Are you currently takin# any "rescri"tion dru#s- Yes No
'lease describe:
::$ Are you in a stable and sae livin# environment- Yes No
Livin# 9ith amily Livin# in care Livin# inde"endently
Livin# in 4I0A unded resource 0omeless 5includes couch3surin#7
(ther livin# situations:
5'lease describe7
1here do you "lan on livin# ater this "ro#ram-
,$ Service 'rovision:
:6$ Are you currently or have you ever received counsellin#- No In 'ast Currently
(why/when/with who/where?)
:=$ a7 Did this counsellin# address substance use concerns- Yes No
(why/when/with who/where?)
:=$ b7 I yes to :=a; 9as the result useul- Yes No
F$ Feedback on Screenin# 'rocess
:>$ 0o9 9as this "rocess or you- (the screening &rocess) +ood Not +ood
Any comments:
To be completed by counsellor
+$ Ne!t Ste"s
'ro#ram Intake: Describe 9hat 9ill ha""en ne!t:
0$ (utcome o screenin#:
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Tick bo!es or belo9
Inormation only 2eerral out Continuin# 9ith service
2ationale or above 507:
Additional Inormation S"eciically or 2esidential 'ur"oses: * o 'revious Stays:
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