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HAVERING DRUG AND ALCOHOL ACTION TEAM
SUBSTANCE MISUSE SCREENING FORM
* indicates mandatory field
Client Information
*
Surname:
*
First Name:
Title:
Previous names
:
Other names:
Preferred name:
*
Date of Birth:
Age:
Ethnicity :
Ethnicity
White British
White Irish
White Other British
Mixed white & black Carabbean
Mixed White & Black African
Mixed White & Asian
Mixed Other
Asian Indian
Asian Pakistani
Asian Bangladeshi
Asian Other
Black Carabbean
Black African
Black Other
Other Chinese
Other Any
Not Stated
*
Gender:
Gender
Male
Female
Tel no:
Mobile number:
Email address:
*
Address:
Client has child care responsibilities:
Yes
No
Age(s) of dependent childcare:
Employment status:
Employed
Casual
Unemployed
Sickness/invalidity benefit
Other
Other
(please specify):
Usually resident in:
[locality]
Substance use and problems
*
What is the defined problem (in their words) Prompts: drugs or alcohol? If drugs, class A or other? Problems caused? Do you want to be treated?
Priority checklist
Client is pregnant
Client is currently injecting drugs
Client has physical health conditions/symptoms that are likely to require treatment
Client has psychiatric problems that are likely to require treatment
Children may be at risk
There is concern about the client's risk of self-harm
There is concern that the client may represent a safety threat to others
There is concern about the offending behaviour
Homelessness/no fixed abode
Action
Are you in touch with a drug treatment agency?
Yes
No
Have you received treatment in another area?
Yes
No
Client is currently in treatment/contact with (please tick):
Non Statutory
GP
Community Mental Health Team
DTTO
CDAT
Adult Care Services
Other type of treatment
(If other specify):
Details of treatment/service:
Concerns of assessor:
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