SAOL Project Programme Referral Form

SAOL Project Programme Referral Form

Referring for: (Please feel free to tick more than one category)

After-Care (Stabilisation) Aftercare (Drug free)

Childcare Community Employment (C.E.)

Key-working/ 1-1 Support IC2 HCV Peer to Peer Training Programme

Reduce the Use 2 RecoverMe

Solas sa SAOL BRIO Programme

WHAT IS SAOL?

The SAOL Project is a person-centred, community-based day programme for women in treatment for drug addiction. Its C.E. programme aims to create positive, meaningful change through an integrated programme of education, rehabilitation, advocacy, childcare provision (with a focus on early childhood education), progression and aftercare supports.

Details of each of the programmes that you can refer your applicant to are available on the website (saolproject.ie); our main programmes are Community Employment (CE), Aftercare programmes (for both ‘drug free’ and ‘stabilising’), BRIO (a new peer training programme for women with addiction and criminality in her history), IC2 Peer to Peer Education and Training, Reduce the Use2, RecoverMe, Individual Support and/or Childcare. You can tick more than one box should you wish to refer your applicant to more than one programme.

Please note that if you are referring your applicant to a CE programme, you will need to complete the accompanying DSP form. This form can be downloaded from the SAOL website.

This form will be responded to as quickly as we can, with people being called for interview in turn (based on date of receiving the form); we attempt to make contact with people within one working week of receiving your referral. To assist us, please ensure that current contact details are fully filled-in. We may contact you at this time to give us any clarifications/additional information that might be relevant to the referral.

PLEASE RETURN THIS REFERRAL FORM TO:
BY POST: SAOL Project

58 Amiens Street

Dublin 1

D01 K253

BY FAX: (01) 8553395

BY EMAIL:

Telephone: 00 353 1 855 3391/3

1 Applicant Information

1.1 Applicant Name ______

1.2 Current Address ______

______

1.3 Date of Birth / /

1.4 Current Telephone No:______1.5 PPS No ______

1.6 Is the applicant aware of this referral? Yes No

2. Referrer Information

2.1 Referrer Name ______

2.2 Position held ______

2.3 Referral Agency ______

2.4 Address ______

______

2.5 Contact No. ______

2.6 How long have you known the applicant? ______

2.7 How long more will you be working with this applicant? ______

2.8 Is the applicant is currently attending an opioid replacement therapy programme?

Yes No

3. Applicant Treatment Profile

If the applicant is being referred to the ‘Drug Free’ Aftercare programme, please ignore question 3.1 to 3.3. SAOL accepts people on ‘Drug Free’ Aftercare who are stable on other prescribed medication.

3.1 Where does the applicant attend for drug treatment? ______

3.2 How many times per week does the applicant attend for their drug treatment? ______

3.3 Has the applicant attended consistently over the last six months? Yes No

3.4 What other medication, is the applicant currently prescribed? (If not known, please tick box)

Medication Daily Dosage

______Not known

3.5 Name of prescribing doctor(s) ______

3.6 Name of counsellor (if any) ______

Name of other Key workers (if any) ______

Name of other significant case workers (e.g. Probation Officer, Social Worker…)

______

3.7a Is the applicant currently being treated for a psychiatric illness that we should be aware of?

Diagnosed Medication and Daily Dosage (if applicable)

Depression Yes No Don’t Know

Anxiety Yes No Don’t Know

Schizophrenia Yes No Don’t Know

Bi-polar Yes No Don’t Know

Other: ______

3.7b If yes, what is the name of the psychiatrist treating the applicant?

______

3.7c Has the applicant ever been diagnosed with a psychiatric illness that we should be aware of?

Diagnosed

Depression Yes No Don’t Know Date when treatment ended: ______

Anxiety Yes No Don’t Know Date when treatment ended: ______

Schizophrenia Yes No Don’t Know Date when treatment ended: ______

Bi-polar Yes No Don’t Know Date when treatment ended: ______

Other: ______Date when treatment ended: ______

Are there any details about previous psychiatric illnesses that we should be aware of?

______

3.8 Are you aware of any circumstances which could hinder the applicant’s full participation in SAOL?

Yes No

Please Explain ______

______

3.9 Do any of the services you provide, and that this applicant must attend, collide with the SAOL attendance time of 9.30 a.m. – 1.30 p.m. Monday to Friday?

Yes No

Please explain ______

______

3.10 (a) Has the applicant linked in with any other relevant support services or agencies?

Yes No

Please describe ______

______

3.10 (b) Is the applicant used to working in group settings?

Yes No

Please give further details:

______

SAOL operates a service called ‘SAOL Beag’, a children’s centre for pre-school children who are one year of age or older. SAOL also operates a ‘Summer School’ for older children (up to age 10) during school breaks. These services provide childcare for participants during class-time and also engage with children in an age-appropriate way as applicants in their own right.

3.11 Does the applicant have any children that will be likely to avail of these services? If so, can you give us some details, including ages of the children?

______

3.12 Is there any additional information you would like to offer about the applicant?

______

3.13 Any other comments?

______

4 Applicant’s Drug Use

Please answer, based on your knowledge and perhaps also drug screening results, each of the following questions. SAOL is not a drug free service, so answering ‘yes’ to questions below will not block the applicant from our services (except the drug free groups, obviously!)

These questions relate to your applicant’s drug use during the last 3 months. To the best of your knowledge:

Has the applicant used heroin in the last 3 months? Yes No Don’t know

Has the applicant used cocaine in the last 3 months? Yes No Don’t know

Has the applicant used crack cocaine in the last 3 months? Yes No Don’t know

Has the applicant used un-prescribed tablets in the last 3 months? Yes No Don’t know

Has the applicant used cannabis in the last 3 months? Yes No Don’t know

Has the applicant topped up with methadone in the last 3 months? Yes No Don’t know

Has alcohol been a problem for the applicant in the last 3 months? Yes No Don’t know

5 To the Referrer

6.1 Are you prepared, as the referrer, to engage in developing and progressing a care plan centred around the applicant’s needs and to attend two meetings with the applicant in Year One of the SAOL Programme?

Yes No

6.2 Please select the most appropriate statement below regarding this referral

I highly recommend this applicant as suitable for the SAOL programme(s) ticked on the first page of this referral form and am willing to engage in developing a care plan with them.

I am unsure which programme(s) the applicant is best for her in SAOL at the moment but am asking SAOL to assess her suitability for them, in the knowledge that I am willing to engage in developing a care plan with SAOL and them.

Other statement ______

______

Signature of Referrer ______Date ______

Version: May 2016 Page 6 of 6