Vancouver Coastal Youth Services

Vancouver Coastal Youth Services

3894 Commercial Street

Vancouver, BC

V5N 4G2

T: 604.871.0450

F: 604.871.0408

SUPPORTED RECOVERY PROGRAM

REFERRAL PACKAGE

Date:______

1.  CLIENT INFORMATION

Last Name______First Name______

Date of Birth______Age______Personal Health Care #______

Gender M F T Street Involvement: Low Med High

Address______

Street City Postal Code

Phone Number______

Last School Attended______Last Grade Completed______

Weight______Height______Eyes______Hair______Complexion______

Distinguishing Marks (scars, tattoos, piercings)______

First Nations: Yes____ No____ If yes, are you a band member? Yes____ No_____

Name of Band______

______

2.  REFERRING AGENCY INFORMATION

Referring Counsellor______Agency______

Phone Number______Fax Number______

How long have you been working with this youth?______

3.  PARENT/GUARDIAN INFORMATION

Guardian/Parent of youth______Phone number______

Address______

Street City Postal Code

Is the Youth in Care? Yes_____ No____

Social Worker______Phone Number______

______

4.  LEGAL INFORMATION

Does the youth have a Probation Officer? Yes___ No___

If yes, Name______Phone Number______

If yes, what has the youth been charged with? ______

______

5.  MEDICAL INFORMATION

Is this youth currently on any prescription medication? Yes_____ No_____

If yes, Name______Purpose______

Has the youth suffered from any of the following:

o  Asthma/Allergies/Hay Fever
o  Nervous Trouble or Breakdown
o  Head Injury or Concussion
o  Dizzy Spells or Fainting
o  Convulsions or Fits
o  Frequent Headaches
o  Nose/Throat Trouble
o  Ear Trouble/Deafness
o  Eye Trouble
o  Lung Disease or Chronic Cough / o  Skin Condition
o  Motion or Travel Sickness
o  Heart Trouble
o  Stomach/Bowel/Rectal Trouble
o  Lower Back Pain
o  Kidney/Bladder Trouble
o  Diabetes
o  Broken Bones
o  Drug Allergies
o  Other______

6.  MENTAL HEALTH INFORMATION

o  Attention Deficit
o  Fetal Alcohol Syndrome
o  Obsessive Compulsive
o  Depression
o  Post-Traumatic Stress / o  Anxiety
o  Psychosis
o  Oppositional Defiance
o  Eating Disorder
o  Other______

Has the youth been diagnosed with any of the following?

7.  ADDICTIONS INFORMATION

Has the youth withdrawn from all drugs? Yes___ No____

Length of time not using drugs or alcohol______

Is the youth currently on Methadone?* Yes____ No____ If yes, for how long? _____

Dosage:______

Does the youth have carrying privileges: Yes____ No_____ If yes, how many days?_____

*Please note the youth will need a medical note from their Doctor stating that they have stabilized on Methadone

Drug of Choice______IV Drug Use? Yes____ No____

Substance Used / Method of Use / Amount & Frequency / Age First Used / Date Last Used / Ever Been Hospitalized
Alcohol
Heroin
Illicit Methadone
Other opiates: Codeine/Percodan/Morphine
Cocaine (crack/powder)
Amphetamine
Crystal Meth
Cannabis
Hallucinogens: Ecstasy/LSD/Peyote/Magic Ms
Tranquilizers: BZD/Barbiturates
Inhalants
Other

______

8.  RISK FACTORS

Does the youth have a history of any of the following behaviours?

o  Sexual Exploitation
o  Physically Aggressive
o  Verbally Abusive
o  Sexually Inappropriate
o  Fire setting
o  Other______/ o  Self-harm
Explain______
Date of last harm______
o  Suicidal Ideation
Date of last ideation______
o  Suicide attempt
Explain______
Date of last attempt______

If yes, provide details ______

9.  PROGRAM PLANNING

Is the youth in transition to another program? Yes____ No_____

If yes, provide details______

What is the rationale for this referral? (What are the desired outcomes for the placement?)

Page 2 of 5

DEC 2013

  Basic physical needs addressed

  Stabilized living arrangement

  Reconnection to Ministry supports

  Improvement with mental health

  Reconnection to community supports

  Improved physical health

  Reduced involvement in sexual exploitation

  Reduced criminal/youth justice involvement

  Reduced substance misuse

  Reconnection to family

  Transition to independence

  Reduced street involvement

  Reconnection to school

  Connection to training/employment

Page 2 of 5

DEC 2013

How does the youth plan to work on his/her treatment plan while in the program?

Bcgeu 5 SEPT 2012

  Attend NA/AA meetings

  Apply for IA

  Apply for treatment

  Housing search

  Attend probation apt

  Regular meetings with supports/counselors/psychiatrist

  Attend day treatment program (Watari, DEYAS, Daytox, etc)

  Attend medical appointments

  Spending time with family

  Attend local recreation center

  Attend school program

Bcgeu 5 SEPT 2012

Discharge Plan:

______

Other Professionals Involved:

Name and Positions Phone Numbers

______

______

10.  CONSENT

Youth agrees to referral placement? Yes____ No____

Release of Information to PLEA signed by youth? Yes____ No____

Thank you for your referral.

PLEA______

Community Services Society of B.C.

REQUEST TO SHARE PERSONAL INFORMATION

I, ______, Date of Birth______,

(name of participant or resident)

request that: ______, ______

(name) (position)

share the following personal information:

about me and my participation in PLEA services.

With: ______, ______

(name) (position)

______

(organization)

With: ______, ______

(name) (position)

______

(organization)

With: ______, ______

(name) (position)

______

(organization)

For the purpose of:

I understand that this request expires in one year or I can change my mind at any time and withdraw this request by telling my PLEA worker.

______

Signature of person making request (date)

Request Withdrawn: ______, ______, ______

(name) (date)

Bcgeu