BRACKNELL DRUG & ALCOHOL ACTION TEAM
Initial Screening Form.
Referral SourceDate: / Name of worker: / Contact number:
Agency: / Email address:
Client Information
Surname / First Name / Title
Previous Name / Preferred Name / M/F
Date of Birth / Age / Religion / Ethnicity
Telephone number / Mobile Number
Address (include full postcode)
Next of kin details:
Name: / Relationship / Contact number:
GP details (name, address)
Ethnicity codes
Client has child care responsibilities (please tick) / Yes / No / Details of children
(Names, DOB’s,…)
Pregnant
Expectant Father (please give details)
Current Children’s Social Care involvement
Nature of Children’s Social Care involvement: / Child Protection plan in place:
Child/ren in care of LA: / Name of social worker:
Employment Status / Employed / Casual / Unemployed / Sickness/Disability benefits
Other (please specify)
Accommodation status / Living in own accommodation / NFA / Living with friends/family / Sofa surfing
Other (please specify)
Any other current accommodation issues? (please specify)
Learning Disability? / Yes / No
Dual Diagnosis? / Yes / No
Allocated CMHT worker?
Substance use and related issues
What is the defined problem (in their words) Prompts: illicit or prescription drugs with or without alcohol? Class A or other? Problems caused? Do you want to be treated?
Referrer’s Expectations
Drug use assessmentCurrent drug use: Have you used any of the following in the last 30 days (or prior to remand)?
Recent use / First use
Drug / Frequency / Amount per day / Cost / Route / Date of last use / Date first used / Age
Heroin
Other opiates
Cocaine / crack
Amphetamine
Ecstasy
Cannabis
Hallucinogens*
Benzodiazepine*
Alcohol
Prescribed medication + OTC
Tobacco
Other
* Please specify prescribed or not
Criminal Justice / Yes/No
PPO/IOM
Probation (please state Probation Officer) / If Yes, nature of current involvement:
DRR/ATR
Pending Offences
Prison Release
Sex working? (please tick) / Current? / Previous / Never
Priority checklist
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 /
Client has received Hep B vaccination /
Client has received Hep C vaccination /
CONSENT(Explicit)
The informationyouprovideon thisform will beheldBracknell Forest Council’s Local Area Screening and Referral Services and SMART (ThePrime Provider)andusedbythePrime Provider forthepurposesofproviding thehelpyou needandensuring thecontinuityofyourhealthcare.
Informationinidentifiedfieldson theform maywithyourconsentbesharedwithNational Drug Treatment Monitoring System(NDTMS). The NDTMS system involves collecting information about the type of treatment you receive from a treatment agency. Sometimes you may be seen by more than one agency. Consequently, to avoid duplication of reporting NDTMS may share information about you between agencies from who you may have received treatment.
Your full name and address are not passed on to the NDTMS although some details are sent to minimise the risk of you being counted twice; for example your initials, date of birth, gender, postcode (partial unless there is local consent), ethnicity and local authority of residence.
Some of the information from the NDTMS is cross referenced with data from other government departments and reports are sent back by Public Health England to them, so that they can monitor the effectiveness of the national drug and alcohol strategies. However, by the time Public Health England reports from the NDTMS to other government departments it is always in the form of total numbers of people and there is nothing in the information that could be used to identify you.
Public Health England does not pass any identifiable information held on the NDTMS to the police or criminal justice agencies.
Your information is held on the NTDMS for at least eight years.
Data from the NDTMS is not placed on any register of addicts – no central register exists.
Your information is very useful for helping to plan and develop services that can best meet your needs. In order to produce information that measures this, the NTDMS data is matched with other government departments data. All data matching is undertaken by Public Health England, and at no point is you personal information shared with other government bodies.
If you do not want information to be passed on to Public Health England you have the right to say this.
If you wish to know more about the NDTMS (including why information is needed for the NDTMS, how the information is handled within the NTDMS and/or the type of information collected for NDTMS and the time it is retained) please ask your key worker.
You have the right to apply for access to any records kept about your health.
Yourinformationwill notbeusedfor anyotherpurposeandwill notbepassed toany other thirdpartywithout yourpermissionsave that theTreatment Provider mayshare yourinformationwith thecertainlawenforcement agencies, otherpublicauthoritiesor othersfor thepurposesof thepreventionor detectionofcrime or where there are concerns in respect of safeguarding young people or vulnerable adults.
Ihavebeenadvised that I canwithdrawmyconsent tothisinformationbeingsharedwith NDTMS and Bracknell Forest DAAT atanytimeandthatifI donot consent tomy information beingsharedwithNDTMS and Bracknell Forest DAAT itwill notprevent megetting the treatment Ineed.
Consent – (other)
It is recognised that people cannot overcome addiction without support. Information also needs to be shared with other professionals in order to ensure that they work collaboratively in the best interests of the individual. This must be explained clearly at the start of the recovery journey and, where possible, a family member or friend should be identified who will support the recovery process. Supporting information should be provided as to the level of contact or support that can be expected from the identified agencies/people.
BracknellForest Substance Misuse Consent to share informationSupport available and assessment to be shared with: (Lead name where relevant)
Carer/Family member/Friend / Yes/No
GP / Yes/No
Community Mental Health Team / Yes/No
Other drug/alcohol, service / Yes/No
Social Services / Yes/No
Probation / Yes/No
Accommodation Provider / Yes/No
Jobcentre Plus / Yes/No
FIP/PEIP / Yes/No
If it seems you have dropped outof service can we pass your name onto outreach? / Yes/No
Other (please specify) / Yes/No
Supporting information
Individual:……………………………………… / Assessor:…………………………………………….
Referral
When completed please forward this completed form to:
New Hope, Units 16/17, Market Street, BracknellRG12 1JG
Tel: 01344 312360
Fax: 01344 353272
Or
Screening conducted by
NameAgency
Date / Time
Comments
Signature of agreement of the transfer of information
I understand I will be referred on or offered a more detailed assessment and a care plan will be developed.
Client / Date