Referral

APT Foundation External Referral for Residential Services
Please do you best to complete the following in as full and honest detail as possible

1 Main

2 Medical

3 Emotional/Behavioral

4 Living Environment

Clear all entries

First name

Last name

Middle name

Date of Referral

Are you a previous APT Client?

If so, which location

Program applying to

Referring Agency

Referring Agency Contact Name

Contact #

Contact Email

Demographics:

DOB

Primary Telephone #

Gender

Ethnicity

Race

Primary Language

Secondary Language

Income

Income Source

SS#

Insurance

Policy Number

Type

Pregnancy:

Do you have children?

# of Children

Age of child/s:

Are you currently pregnant?

Pregnancy Due Date

Bring children into treatment

Is there DCF Involvement

DCF Case Worker Name/Number:

Conservatorship:

Do you have a conservator?

Name of conservator

Phone #:

Is it for finances?

Is it for person?

Legal:

Are you currently on probation/parole?

Probation/Parole officer Name

Contact Number

Do you have pending charges?

If yes, for what charges?

What court (s)

What date (s)

Are you being mandated to treatment?

Are you aware of PREA (Prison Rape Elimination Act)?

Have you ever been a victim of sexual abuse or harassment while incarcerated?

Have you ever been a victim of sexual abuse or harassment in the community?

2

Withdrawal

Are you currently experiencing withdrawal symptoms?

Select all that apply

On a scale of 1 to 5 (1 being manageable and 5 being unmanageable) how do you rate your symptoms?

Are you currently on medications to assist with cravings or withdrawal?

Which medications?

Current Dose

Other withdrawal medications

Do you feel stable on your current dose?

Medical

Do you have current health issues?

If yes, please describe.

Do any of these issues make it harder for you to take care of yourself?

One a scale of 1 to 5 (1 being manageable 5 being unmanageable) how do you rate this difficulty?

Do these make it harder for you to engage substance abuse treatment?

Are you currently taking prescribed medications?

If yes, what medication/dose/frequency:

Who is the prescribing doctor?

Last pharmacy used:

Do you have difficulty with your vision?

Do you have difficulty with your hearing?

Do you require a wheelchair?

Cane?

Walker?

Can you dress without assistance

Can you transfer to the toilet independently?

Can you shower independently?

Have you experienced seizures?

If so, what type?

How often?

When was the last one?

Were you detoxing from substances?

Do you have any medical appointments scheduled?

If so, dates/times

Are you willing to change appointments until treatment is completed at RSD?

DISCLAIMER: If you are unwilling or incapable of changing the appointment, the program does not guarantee the ability to accommodate your appointments.

3

Mental Health:

Are you currently engaged in mental health services?

If yes, where?

How long have you received services?

What are yours current diagnosis?

Are you currently experiencing any mental health symptoms (please list):

Check the box that applies best to your mental health

Are you currently experiencing auditory hallucinations or visual hallucinations?

If yes, when was the last time?

Does your mental health make it harder for you to engage in substance abuse treatment?

Do you feel that these issues have caused, or made your substance abuse worse?

Do any of these issues make it harder for you to take care of yourself?

Do you believe that your mental health has had an impact on your life?

If yes, name all the areas it has had a negative impact (Ex: work, relationships, legal issues, etc.):

Are you currently taking prescribed medications?

If yes, what medication, dose, and frequency:

Who is the prescribing doctor?

Last pharmacy used:

Are there any appointments scheduled?

If yes, where and when?

Are you willing to change appointments until treatment is completed at RSD?

DISCLAIMER: If you are unwilling or incapable of changing the appointment, the program does not guarantee the ability to accommodate your appointments.

Suicidal Ideation:

Do you currently have thoughts of hurting yourself or ending your life?

Do you have a plan?

If yes, how?

Are you capable or have the means to follow your plan?

Have you ever experienced thoughts of hurting yourself or ending your life?

Do you have past attempts of suicide?

If yes, how many attempts?

Were you under the influence of alcohol/drugs?

If you answered yes to the first 2 questions, please dial 911 or go to your nearest emergency room.

Homicidal Ideation:

Do you have current thoughts of hurting others?

Do you have a plan to hurt anyone?

Do you have the means to hurt that person?

Have you had thoughts about hurting others in the past?

Describe when and circumstances:

Were you under the influence of alcohol/drugs?

Did you have a weapon?

Disclaimer: If you answered yes to to the first 2 questions, please dial 911 or go to your nearest emergency room.

Substance Use:

Primary Drug of Choice:

Date of last Use:

How much/how often:

Method of Use:

Second Drug of Choice

Date of last Use

How much/how often:

Method of Use:

Third Drug of Choice

Date of last Use

How much/how often

Method of Use

On a scale of 0 (low) to 4 (very high) how important is it for you to stop using alcohol and/or other substances:

Do you believe substance use has had an impact on their life?

If yes, name all the areas it has had a negative impact (Ex: work, relationships, legal issues, etc.):

Are you likely to continue using without residential treatment?

Have you ever experienced an overdose?

If yes, what was the date of the last one?

What substance (s)?

Were you hospitalized for the Overdose?

Are you currently engaged in treatment?

If so, where?

Start date:

Have you been successful in treatment?

Have you recently been successful at stopping or reducing your use?

If so, what have you done?

In the last 30 days I have experienced cravings for alcohol: Occasionally = 1-5 times a month, Frequently = 3x’s per week, Constantly = Daily

In the last 30 days I have experienced cravings for drugs

Do you find yourself spending time searching for your drug of choice?

Are you aware of any triggers to use alcohol and/or substances?

If yes, please describe or list any triggers that can be identified:

Are you aware of any coping strategies that have helped you to stop using?

If yes, please list any skills/strategies you have used to help limit or stop your use:

Check the box that best applies to your substance use:

4

Recovery/Living Environment:

What are your current living arrangements:

Address

Do you need different housing than you currently have?

Do you have relationships that are supportive for your recovery?

Is their current living/social situation unsafe/harmful to your wellbeing/sobriety?

Do you spend time with others that use alcohol and/or drugs?

Where do you plan to discharge to?

Are you currently employed?

Are you currently enrolled in school?

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