CHARLES J. ANDREW YOUTH TREATMENT CENTRE

PO Box 109

Sheshatshiu, Labrador A0P 1M0

Telephone: 709-497-8995 Fax: 709-497-8993

YSAC

Youth Services Intake Form

Referral Information:

Name: ______________________________________

Date of Birth: ________________________ (dd/mm/yyyy) Age at present _____ Male o Female o

Medical Number: ____________________ Province of Registration ________ Expiry Date __________

Band Name and Number (10 digits): ______________________________________

Social Insurance Number (if available): ___________________________________

Treaty Number: _________________________________

Client Address: _____________________________________________________________________________________

__________________________________________________________________________________________________

Languages: Spoken English_____ Other _____ Understood English_____ Other_____

Social Services Involvement:

Agency Name: _________________________________________________

Phone No: ____________________________________

Worker Name: _________________________________________________

Client Status: Crown ward _____ Society Ward _____ Voluntary Placement ____

Customary Care ____ VPA ____ Other _____

Family History:

Biological Parents: _________________________________________________

Guardian: _______________________________________________________

Address:_____________________________________________________________________________________________

____________________________________________________________________________________________________

Phone No: ________________________________________

Place of Employment: ______________________________________________

Phone No: ____________________________________

(Please list all who are considered siblings by the client, including customary, step and foster siblings)

Name

Age

Health Status

Lives with

Extended Family:

Maternal: _______________________________________

Paternal: ________________________________________

Languages: (spoken predominantly, other) __________________________________________________

Religious Beliefs: Traditional o Roman Catholic o Protestant o

Other ______________________

Education:

1. Does your client go to school? Yes o No o

2. Does your client like school? _______________________

3. Highest grade completed? _________________________

4. Name of school and last year attending this school: ____________________________________________

Relationships:

5. Does client live with: Mom o Dad o Alone o Friends Extended Family Members o Siblings o

6. How does your client get along with his/her family members? ____________________________________

7. Who does your client feel closest to? ________________________________________________________

8. Does he/she have any close friends? If so who? _______________________________________________

9. Does he/she talk to any elders? Is he/she willing to listen? _______________________________________

10. Does he/she have a girlfriend or boyfriend? __________________________________________________

11. Is he/she sexually active? _________________________________________________________________

Medical History:

12. Does your client have any medical problems? (please identify) ___________________________________

13. Does he/she require a medical consent form? _________________________________________________

14. Family doctor’s name and telephone number: ________________________________________________

15. Is your client currently on any medication? ___________________________________________________

16. Does he/she have any allergies? ____________________________________________________________

Legal Involvement:

17. Has your client ever been in trouble with the law? (requires record of pending charges and outstanding charges) ______________________________________________________________________________ ______________________________________________________________________________________

18. Was alcohol or any other substances, such as “sniff” or drugs involved during your client’s legal problems? ______________________________________________________________________________________

19. Is your client currently on probation or on a court order? o Yes o No

Name of probation officer: ___________________________________________

Phone No: ________________________________

Fax No: ___________________________________

Probation Order: From ____________________________ to ________________________

Conditions: _____________________________________________________________________________

Copy Attached? Yes o No o

*A copy of the probation order is mandatory

Solvents/Substance Abuse:

Chemical Use History:

20. At what age did your client start sniffing ___________

21. At what age did your client start alcohol ______________

22. At what age did your client start using other drugs _________________

23. Has your client ever used any of the following?

Substance	Yes	No	How long? (months/years)
Gasoline
Glue
Cigarettes
Spray Paint
Rubber Cement
Nail Polish Remover
Hard Liquor
Marijuana
Fabric Protector
Crack
Beer
Other
Other

24. Does anyone else in his/her family use solvents/substances? Yes o No o

25. If so, who else? ________________________________________________

26. What solvents/substances are mainly used? _________________________

27. Does he/she use solvents/substances with others or by him/herself? ______________________________

28. Where does your client usually use?

Place	Yes	No	Place	Yes	No
At home			Abandoned Car or Truck
A Friend’s House			At a party
School			Outdoors
Abandoned Building			Other

29. Has your client ever lost friends because of sniffing or huffing? Yes o No o

30. Has your client ever gotten into any physical fights when using? Yes o No o

31. Has your client ever caused serious injury to others? Yes o No o

Please explain:

______________________________________________________________________________________

32. Has he/she been diagnosed with any medical, physical, psychological, emotional problems because of the use

of solvents/substances? Please provide a copy of the psychological assessment.

Explain: _______________________________________________________________________________

33. Does he/she feel that they have control over their use of solvents/substances? Yes o No o

34. Has he/she ever considered reducing or quitting? Yes o No o

35. Has he/she ever been in any previous treatment for their use of solvents/substances? Yes o No o

Where _____________________________________ When____________________________

· Please provide a copy of the completion report

36. How long did the client stay in the program? _______________________

Psychological Functioning

37. Has your client ever spoken or wrote about killing him/herself? Yes o No o

38. Has your client ever attempted to kill him/herself? Yes o No o

39. How many times? _____________________

40. How did he/she attempt to kill him/herself? __________________________________________________

41. Has the client frequently gone off on their own when he/she is depressed (unhappy)? Yes o No o

42. Is the client sad/unhappy? Yes o No o

q None of the time q Some of the time q Most of the time q All of the time

43. Is there any known history of sexual, physical or emotional abuse? Yes o No o

44. Is there any known history of physical abuse? Yes o No o

45. Is there any history of emotional abuse? Yes o No o

46. Please explain: (at what age? Has it been reported and what is the outcome or current status:

____________________________________________________________________________________

47. Is there any history of family violence that this child may have been witness to?

Please explain: ________________________________________________________________________

When the client is in a sober state:

48. Has he/she communicated with spirits that no one else can see or hear? Yes o No o

49. Has this happened? q Never q Sometimes q Most of the time

50. Are these positive or negative experiences for the client? ______________________________________

51. Are there times when people are unable to communicate with the client? Yes o No o

q Not at all q Sometimes q Most of the time q All of the time

52. Has your client ever had any psychological testing or counseling? Yes o No o

For what purpose? ______________________________________________________________________

Outside Resources:

53. Are there any other agencies involved with your client and his/her family? Yes o No o

54. If so, which ones and what services do they provide ( for example, NNADAP, CHR, CFS)

______________________________________________________________________________________

Family:

55. Family activities/practices: What do you see as a family?

______________________________________________________________________________________

56. Family roles/relationships: How do they interact with each other?

______________________________________________________________________________________

57. Status in the community: How is the family perceived in the community?

______________________________________________________________________________________

58. What type of belief system is practiced? _____________________________________________________

59. How does he/she spend their leisure time? ___________________________________________________

60. Who are other support people involved with the family? (example: elders, extended family, community

groups, community workers, CHR, NNADAP, CWPW) ___________________________________________

61. Is the client/family aware of the effects of solvents/substances?

Client Yes o No o

Family Yes o No o

Community Worker Yes o No o

62. Does the family believe the client recognizes that he/she has a problem? What steps does the family want

to take to address the problem?

_______________________________________________________________________________________________

63. Has anyone in his/her family or community received treatment for solvent/substances abuse?

______________________________________________________________________________________

64. Are the parent(s) supportive of their child receiving treatment? (refer to referral agent agreement and parental

consent form) ___________________________________________________________________

65. Upon the child’s completion of the program, what type of support system do you see as effective/useful to

help maintain a clean lifestyle for self/child?

______________________________________________________________________________________

66. Are the extended family members supportive of the family seeking help and/or treatment for themselves

or their child? __________________________________________________________________________

67. Would the family be willing to come to our treatment centre to observe the program in action as part of

the intake process? ______________________________________________________________________

68. Significant losses or areas that may be affecting the child related to unresolved grief

______________________________________________________________________________________

Workers Recommendations:

Indicate what areas of healing he/she feels we should concentrate on?

____________________________________________________________________________________________________________________________________________________________________________

Any additional information that your client or family feels might contribute to his/her treatment?

____________________________________________________________________________________________________________________________________________________________________________

Parent/Guardian Signature: ________________________________________________________

Youth Signature: ______________________________________________________

Referral Worker Signature: _________________________________________________

Date: __________________________________

CHARLES J. ANDREW YOUTH TREATMENT CENTRE

PO Box 109

Sheshatshiu, Labrador A0P 1M0

Telephone: 709-497-8995 Fax: 709-497-8993

Dear Health Care Provider

Attached please find the Medical Assessment Form required for individuals who have been accepted for voluntary admission to the Charles J. Andrew Youth Treatment Centre.

The Centre is a ten bed residential youth healing Centre for female and male youth between the ages of 11-17 and serves Innu, Inuit, and First Nations youth from Atlantic Canada and across Canada. The main goal of the 16-week program is to assist adolescents in regaining their self-confidence through an addictions treatment program designed to help them become healthy independent adults.

The Charles J Andrew Youth Treatment Centre has two components to its treatment plan, a Clinical component and a Nutshimit component which involves relearning or learning a traditional way of life that is passed on to youth by Elders. Each component runs on alternating weeks.

The Nutshimit Program includes a life skills portion, which is done on the land. During Life Skills clients receive training in areas of food preparation, survival skills, sweat ceremonies, healing circles, hunting, fishing, canoeing, snow-mobiling, hiking, snow-shoeing, berry picking, pitching a tent and breaking camp, and traditional crafts.

The objectives of the Medical Assessment are:

· To provide information on:

o pertinent medical history that should be available to health care providers should the client need health care while at the center

o medications

o allergies

o dietary restrictions

· To ensure the client is free from communicable diseases that would be a risk to others.

· To identify any health limitations that precludes entry into the program or would require modified activities.

CHARLES J. ANDREW YOUTH TREATMENT CENTRE

PO Box 109

Sheshatshiu, Labrador A0P 1M0

Telephone: 709-497-8995 Fax: 709-497-8993

MEDICAL ASSESSMENT FORM

PERSONAL INFORMATION

Youth Name:________________________________________________________________________

Surname First Name Middle

Date of Birth: _____/______/______ Health Card No.: _____________________________

Name of Band: ___________________________Band No.:___________________________________

MEDICAL INFORMATION

1. Please provide any pertinent medical history that should be available to a health care provider should the client need health care while at the Treatment Center.

2. Is the client on any medications? Yes No

If yes, please list the name of the medication, the dose etc.:

3. Does client have any allergies? Yes No

Comments:

4. Does client have any dietary restrictions? Yes No

Comments:

Do these dietary restrictions require medication? Yes No

5. Does the client currently have a communicable disease that would be a risk to others?

6. Has the client been checked and cleared by a public health nurse or other medical professional for head lice? Please provide date of check and status:

7. Tuberculosis:

a. Does the client have any signs or symptoms consistent with active tuberculosis? Yes No

If yes ensure that the client is investigated for TB and is not infectious before entering the

Treatment Center.

b. Date and result of the most recent Tuberculin Skin Test (TST):

c. Date and result of the most recent Chest X-ray if TST positive:

8. Is the client pregnant (female applicants)? Yes No

Comments:

9. Are you aware of any additional medical condition or limitations that may influence the client’s participation in the program? Yes No

If yes, please explain:

10. Please provide an up to date copy of the client’s immunization record

*************************************************************************************

I hereby certify that I have examined the above named as required and the said person is physically and mentally fit to undertake the program offered by the Charles J. Andrew Youth Treatment Centre.

Physician’s Name: __________________________________________________

Please Print

Address: ______________________________________________________________________

______________________________________________________________________

Telephone: _____________________________ Fax: _______________________________

Physician’s Signature: _________________________________________________

CHARLES J. ANDREW YOUTH TREATMENT CENTRE

PO Box 109

Sheshatshiu, Labrador A0P 1M0

Telephone: 709-497-8995 Fax: 709-497-8993

Youth should bring the following:

Clothing:

· Appropriate outdoor clothing/footwear for the season (keeping in mind we will be snowmobiling, boating, camping, fishing and hunting)

· Appropriate sleepwear

· Everday clothing (jeans, t-shirts, underwear, etc.)

· Shorts/Skirts to participate in cultural sweat

· Swimwear

· Sandles for shower and slippers

Toiletries:

· Razor/shaving cream

· Toothbrush/toothpaste

· Shampoo/body wash/scrubby

· Aftershave/deodorant (no perfume or cologne please)

Medical:

· Health care card ( Must be up to date and valide for the duration of the program)

· Prescription medication (if applicable)

· Status card

Following items are not permitted:

· Cell phones

· MP3 players / I-Pods

· Video games/consoles

· Laptops / tablets

· Junk food

CHARLES J. ANDREW YOUTH TREATMENT CENTRE

PO Box 109

Sheshatshiu, Labrador A0P 1M0

Telephone: 709-497-8995 Fax: 709-497-8993

FOOD/MENU

The Charles J. Andrew Youth Treatment Centre is commited to providing nutricious and healthy meals for clients during their stay at the Centre. In an effort to assit in menu designing, please list the foods your youth will ABSOLUTELY not eat. The Centre will do its best to try and accommodate your youth, but keep in mind that nutricious and healthy meals will continue to be served and may contain some of the items you’ve listed below.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

CHARLES J. ANDREW YOUTH TREATMENT CENTRE

PO Box 109

Sheshatshiu, Labrador A0P 1M0

Telephone: 709-497-8995 Fax: 709-497-8993

Transition to Education Request Form

Education is an important part of each client’s stay at CJAY. Clients are expected to attend the education component of their treatment program on a daily basis, and must respect the learning environment they will be enrolled in while in treatment.

To help with the successful transition from their current school/academic environment to the CJAY classroom, we ask that all clients bring or forward the following subject materials:

English	Mathematics	Other Studies
* Workbooks * Letters from client’s English and math Teachers explaining what educational materials should be learned * Marking and/or progress charts (welcomed!) * Any other peripherals such as course outlines and notes * Textbooks		Books of interest
		Other subject materials, if desired
		Letters from the appropriate teachers explaining what educational materials would be useful to review
*Class novel/fiction literature	Worksheets	Projects of interest

* Pertinent to transition

CJAY has some access to provincial textbooks and materials; however, it is best for clients to bring their own workbooks and/or directions from their teachers, so the client’s schoolwork while at CJAY can be directly credited to their missed schooling while in treatment. In addition, when a client brings their own subject materials, they prevent any gaps in learning while removed from their regular classroom.

CJAY will evaluate and record student progress and provide all learning tools for the client while in treatment. If the client is unable to gather or mail any subject materials or teacher correspondence, CJAY will do its best to assess and place the client within the educational program, and will provide an education for the client while in treatment.

Mailing addresses:

Materials can be mailed directly to CJAY or forwarded to the Labrador School Board in Happy Valley-Goose Bay.

Charles J. Andrew Youth Treatment Centre PO Box 109 Sheshatshiu, NL A0P 1M0

Labrador School Board (East) Attention: Charles J. Andrew Youth Treatment Centre PO Box 1810, Stn B Happy Valley-Goose Bay A0P 1E0

CHARLES J. ANDREW YOUTH TREATMENT CENTRE

PO Box 109

Sheshatshiu, Labrador A0P 1M0

Telephone: 709-497-8995 Fax: 709-497-8993

ASSESSMENT QUESTIONNAIRE

Youth Name	Date
Date of Birth	Gender Male Female
NIHB:	Provincial Health Care No.
Current Mailing Address
Telephone Number	Emergency Number

EMERGENCY CONTACT INFORMATION

Mother’s Name **	Martial Status
Address
Telephone Number
Father’s Name **	Martial Status
Address (if different from above)
Telephone Number
Legal Guardian’s Name	Relationship to youth
Address
Telephone Number
If parents separated: If applicable, Mother’s current partner’s name If applicable, Father’s current partner’s name
Restrictions on contact with youth? Please list all people who may not have any contact with the youth during their stay at the treatment centre

** If parents are separated/divorced, please provide a copy of the separation/divorce agreement which deals with custody and access to the child

LEGAL GUARDIAN STATUS

	Yes	No	Dates
Voluntary Care Agreement
Ward
Adopted
Foster Care
Customary Adoption
Documentation Available Yes o No o Document: Source: Date:

REFERRAL SOURCE

Agency’s name
Address
Telephone Number	Fax
Referent	Title
Relationship to youth

MEDICAL HISTORY

Has the youth been diagnosed with FAS, FAE, or ADHD? Yes o No o If yes, what medications are prescribed?
Does the youth have anti-social or self destructive Yes o No o behaviours requiring intensive therapeutic intervention If yes, please describe:
Date of last visit to Dentist: Date of last visit to Optometrist:
Doctor/Clinic Name: Telephone: Fax:
Allergies:
Menstruation Cycle Regular? Yes o No o
Is s/he sexually active? Yes o No o
Does he/she have a boy/girlfriend? Yes o No o
Do he/she have children? Yes o No o
Children’s names:	Age:

SUBSTANCE ABUSE EXPERIENCE

Preferred substance:
Have the youth tried any of the following substances	Yes	No	How often	Age of first use	Last date used
Gasoline
Glue
Propane
Nail Polish/Remover
Pain
Contact Cement
Marijuana
Hashish
Beer
Hard Liquor
Cigarettes
Other

SUBSTANCE ABUSE INTERVENTION

Has the youth tried self controlled Yes o No o How often

Abstinence?

Has the youth tried AA or NA ? Yes o No o How often

Has the youth attended treatment Yes o No o Year:

Before?

Was treatment completed? Yes o No o

If no provide reasons

ABUSE

Family issues (in home)	Yes	No	Comments
Physical abuse
Emotional abuse
Substance abuse
Sexual abuse
Abuse issues (to youth)	Yes	No	Comments
Physical abuse
Emotional abuse
Sexual abuse

FAMILY AND HOME ENVIRONMENT

Was the youth adopted? Yes o No o

Has the youth ever been in foster care or removed from his/her home? Yes o No o

Do either of the primary caregivers abuse alcohol, drugs, or solvents? Yes o No o

Are there other people living in the youth’s home who abuse drugs, alcohol, drugs, or solvents? Yes o No o

If yes, are they related to the youth? Yes o No o

Does the youth have positive role models in the family setting Yes o No o

If yes, who?

Does the family indicate an interest in family therapy? Yes o No o

If no, why not?

SCHOOL AND RECREATION

Is the youth presently in school Yes o No o
Name of Youth’s school:
Present Grade:	Date when last attended school regularly:
Last Grade completed:	Year
Did the youth ever attend school while high on drugs, alcohol, and/or solvents Yes o No o If yes, how often and severity of problem:
Is truancy a problem for the youth? Yes o No o If yes, provide details:
Does the youth require general monitoring at school work in order to complete task? Yes o No o
Does the youth have a learning problem which requires a specialized academic program? Yes o No o If yes, explain:
Does the youth have severe learning problems or behavioural problems that require Yes o No o intensive individual programming? If yes, explain:
Is the youth involved in extra-curricular school activites for example: sports, clubs, drama, etc… Yes o No o If yes, please provide details
Does the youth enjoy group recreational activities Yes o No o For example; board games, sports, dances If yes, Please provide details
Does the youth regularly participate in crafts or art work? Yes o No o
Does the youth play a musical instrument Yes o No o If yes, please provide details:

INDEPENDENT LIVING SKILLS

SKILL	APPROPRIATE	CHALLENGED	COMMENTS
Cooking
Household Chores
Laundry
Budgeting
Personal Hygiene

SUPERVISION AND BEHAVIOUR MANAGEMENT

Does the youth require more supervision, structure and routine than his/her peers? Yes o No o

If yes, please provide details:

Do any of the youth’s siblings have any behavioural management issues? Yes o No o

If yes, please provide details:

Does the youth require medication to assist in the management of his/her behaviour? Yes o No o

If yes, what medications:

Does the youth have a history of setting fires? Yes o No o

If yes, please provide details:

Does the youth have a history of demonstrating cruelty to animals? Yes o No o

If yes, please provide details:

Does the youth have a history of destroying property? Yes o No o

If yes, please provide details:

Does the youth have an eating problem? Yes o No o

If yes, please provide details:

Has the youth experienced changes in weight or eating habits? Yes o No o

If yes, please provide details:

Does the youth have a history of physical aggression towards peers? Yes o No o

If yes, please provide details:

Has the youth ever run away from home? Yes o No o

If yes, please provide details:

Does the youth experience sleeping problems? Yes o No o

If yes, please provide details:

Does the youth have a history of suicide attempts Yes o No o

If yes, how often?

Methods used?

Does the youth have a history of acting out sexually? Yes o No o

If yes, please provide details:

INTER-DEPARTMENT, INTER-AGENCY INVOLVEMENT

Has the youth been involved in the criminal justice system? Yes o No o

If yes, please provide details:

Charges:

Court Date:

Is the youth currently on probation? Yes o No o

If yes, please provide details:

Probation Officers name:

Telephone number:

Address:

Charges:

Court Date:

Conditions of under taking:

Does the youth have a lawyer? Yes o No o

If yes, please provide details:

Name:

Telephone number:

Address:

Has the youth been involved with any of the following professionals?

o Social Services

o Court Worker

o Mental Health Worker

o Therapist (psyco metrist, psychologist, psychiatrist, social worker, occupational therapist)

o RCMP

o Others

o Not applicable

LOSSES

Has the youth lost a family member to:
Type of Loss	Yes	No	Year	Relationship	Circumstances
Illness
Divorce/Separation
Incarceration
Accidents
Suicide
Murder

RELATIONSHIPS

With whom does the youth have significant reationship?

Does the youth have close friends? Yes o No o

If yes, does the youth abuse substances with these friends? Yes o No o

Does the youth have a good relationship with any of the following?

o Parents o Siblings o Extended Family

Of the above who is the primary role model?

o Parents o Siblings o Extended Family

Has the youth been involved in any of the following?

o Aboriginal Traditional Practices o Church Groups o Community Groups o Social or Sports Clubs

Does the youth feel he/she “fits in” with the group? Yes o No o

If no, please provide details:

Does the youth get along with other people? Yes o No o

If no, please provide details:

Does the youth make friends easily? Yes o No o

Is the youth satisfied with his/her family relationships? Yes o No o

Please provide details:

FAMILY STRENGTHS

Does the family communicate well together? Yes o No o

If youth has been adopted or is in foster care, does the youth have good Yes o No o

communication with biological parents?

Does the family participate in traditional/cultural activities together? Yes o No o

Does the family access community support? Yes o No o

Has anyone in the family attended treatment before? Yes o No o

If yes, please answer the following:

Relationship to youth:

Program:

Duration:

Was the program completed?

Other strengths:

HOLISTIC VIEW OF YOUTH

SPIRITUAL

Please provide a brief description of the youth’s spiritual development:

MENTAL

Please provide a brief description of the youth’s overall cognitive and social development:

PHYSICAL

Please provide a brief description of the youth’s physical well being. Are there any impairments because of substance abuse? Does the youth have any physical disabilities?

EMOTIONAL

Please provide a brief description of the youth’s overall emotional functioning. Do you perceive the youth to be at risk of self-harm? Does the youth have a history of abuse (physical, emotional, spiritual, or sexual? If so, please provide details:

YOUTH’S EXPECTATIONS (TO BE COMPLETED BY YOUTH)

Why do you want to come to treatment?

What do you think are some of the best things about you?

What are some issues you are having trouble dealing with?

What do you expect from treatment?

Check some of the ways we may be able to help when you are upset:

o Talk to me o Go for a walk with me o Sweat/Smudge o Arts/Crafts o Just listen to me o Sports o Journal writing o Exercise o Let me talk to a friend o Outdoor Activity o Let me be by myself o Talk in an office

Is there anything else we should know that you feel would help us help you during your healing journey here with us?

I declare that the information on this referral form is true and accurate to the best of my knowledge.

Youth Signature: ________________________________________________________

Parent Signature: ________________________________________________________

Legal Guardian(s) Signature: ________________________________________________________

Referent’s Signature: ________________________________________________________

Date: ________________________________________________________

CHARLES J. ANDREW YOUTH TREATMENT CENTRE

PO Box 109

Sheshatshiu, Labrador A0P 1M0

Telephone: 709-497-8995 Fax: 709-497-8993

YOUTH SUBSTANCE USAGE QUESTIONNAIRE

A. General observation: size, hygiene, well being, other: _________________________________________

B. Interaction with adults: (avoidance/normal/outgoing): ________________________________________

C. Family background: _____________________________________________________________________

D. Is the youth seeking to change his/her behaviour? (yes / hesitant / no)

Name: ____________________________________ Gender: Male ________ Female ________

Community: ___________________________________________________________________________

DOB: _____________________________________ Age of youth now: ______________________

Last Grade: ________________________________ Last School attended: ____________________

Date questionnaire completed by youth: ____________________________________________________

Administered by who: ___________________________________________________________________

Accepted for treatment: _____________________ Date expected: _________________________

General Inquiries:

E. How old were you when you first used? _____________________ How long? ___________________

F. Who did you learn from? (sibling / friend / aunt / uncle / parent / other)

G. What things have you used? ______________________________________________________________

H. What drugs have you tried? ______________________________________________________________

I. With whom? (friend / siblings / adults / alone / other) ________________________________________

J. Locations? (home / bushes / old buildings / other) ___________________________________________

K. Time(s) (afternoon / suppertime / getting dark / late at night / whenever you can)

L. Have you ever tried to quit on your own? Yes / No

Have you attened treatment before? Yes / No

If yes, where: __________________________________________

Did you finish? Yes / No

If no, why? ____________________________________________

1. Do you know that using is dangerous to yourself and others? Yes / No

2. Have you ever refused to talk about your substance abuse? Yes / No

3. Are these some of your reasons why you use?

All my friends are doing it? Yes / No

I don’t have any friends? Yes / No

Nobody likes me? Yes / No

Nobody cares what I do? Yes / No

I am mad, upset, hurt? Yes / No

Because I like it? Yes / No

There’s nothing to do? Yes / No

4. Have you ever heard or seen things while you were high? Yes / No

5. Do you need to sniff in order to be accepted by others? Yes / No

6. Is it easy for you to find substances to get high? Yes / No

7. Have you ever thought that you just couldn’t wait? Yes / No

8. Do you ever sneak around to get high? (at lunch time/after school) Yes / No

9. Have you ever done things that were dangerous to yourself or others while you were high Yes / No

10. Have you ever felt guilty or ashamed about some of the things you did when you were high Yes / No

11. Have you ever noticed that it takes more or longer to get hight than it used to? Yes / No

12. Are these some other personal reasons why you are using?

There are lots of family problems? Yes / No

Parents are drinking? Yes / No

There are problems at school? Yes / No

You are in care? (foster/group) Yes / No

13. Have you ever hidden a supply to get high later? Yes / No

14. Have you ever felt sorry for yourself? That you were being picked on? Yes / No

15. Have you ever tried to control your using, by intending to get just a little high,

but ended up using more? Yes / No

16. Have you ever experienced a blackout? A period of time when you couldn’t

remember what you did after using? Yes/ No

17. Have you ever had thoughts that repeated themselves over and over? Yes / No

18. Have you ever had friends that won’t hang around you because you are using? Yes / No

19. Have you ever been late for school because you were high? Yes / No

20. Do you have the sense of not being connected with family or people around? Yes / No

21. Have you ever sensed that using was affecting your favourite reactional activities? Yes / No

22. Have you ever been taken to the emergency room because of your using? Yes / No

23. Have you ever been hurt in an accident while you were high? Yes / No

24. Do you have problems remembering recent events or that your thing was

becoming confused? Yes / No

25. Have you ever noticed that you got high on using less? Yes / No

26. Have you ever been scared, nervour or afraid of something without knowing

what you were afraid of?