Counseling Referral (DHS)
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Client Information:
Client Name:
Phone
#: |
| Case Numbers:
(if applicable)
C-
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or
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(DHS Only) KK:
Date of
Sentence:
(if applicable)
Date of Birth: |
Referral Source Information: (Name of person who needs progress
reports, incident reports, UA results, etc.) |
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Referral Name:
Work Number:
Fax Number: |
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Email
Address:
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| Recommended Services:
(Check all services you would
like the client to participate in) |
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DUI
Assessment |
English |
Spanish |
Consists of one 2 ½-hr. session. |
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Substance
Abuse Assessment |
English |
Spanish |
Consists of one 2 ½-hr. session. |
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10
Hour ADSAC (DUI) School |
English |
Spanish |
Consists of three 3 ½-hr. sessions. |
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24
Hour ADSAC (DUI) School |
English |
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Consists of twelve 2-hr. sessions. |
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Victims
Impact Panel
Consists of one 2-hr. session, facilitated by (MADD)
Mothers Against Drunk Driving |
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DUI
Outpatient Programs |
English |
Spanish |
6-week
program |
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12-week
program |
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ATR (Access to Recovery) Assessment-
Provides free transportation, housing, medical, food,
and employment services |
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Relapse
Prevention/Aftercare Programs-
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6-week
program |
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12-week
program |
Criminal Thinking (lmpulse
Control)
Program -
12-24 week
program for adolescents and adults, designed to
challenge and
correct irresponsible and criminal thinking and
behavior, 1 ½ hours per week |
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Anger
Management/Coping Skills Program-12-week
program for adolescents and adults, 1 ½ hours per week.
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Early
Intervention Programs |
English |
Spanish |
6-week substance abuse education
program for adults and |
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12-week substance
abuse education program for adolescents. Random Drug
Testing provided (if UA
referral form completed) |
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Outpatient Programs |
English |
Spanish |
6-24 week program for
adults and adolescents. |
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Random
Drug Testing, individual, group, and self-help meeting
attendance is required. |
Intensive
Outpatient Programs
- 12 week program (9-12 hours per
week) for 6-weeks and 6-weeks of aftercare for adults.
12
week program (6-9 hours per
week) for 6-weeks and 6-weeks of aftercare for adolescents. Individual, group, and self-help
meeting
attendance is required. Random Drug Testing
required. |
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(SFP) - Strengthening Families Program -
SFP is a “Free”
outpatient program presented in a 14 week format with
highly structured, consecutive weekly sessions, each
lasting approximately 2 hours.
Which is aimed at
“Treating
the Whole Family” (Parents and Children),
to help heal, implement a recovery based model and
assist in family reunification for your clients.
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Level Of
Identified Risk: (Level
checked indicates the risk of relapse/continued use or
other behavioral/family problems) |
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Low
Risk - (Risk is minimal) Early
Intervention referral is indicated |
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Medium
Risk
- (Risk is moderate) Extended Outpatient referral with
additional family services is indicated |
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High
Risk - (Risk is extreme)
Intensive Outpatient referral with additional family
services is indicated |
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Case history, evaluation results, or
comments supporting assigned level of risk: |
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