Counseling Referral (DOC)
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Client Information:
Client Name:
Phone
#:
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| 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) |
ASSESSMENT SERVICES: |
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DUI
Assessment: |
English |
Spanish |
Consists of one 2 ½-hr. session. |
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Substance Abuse Evaluation: |
AAP-
Prostitution |
Family
Court |
Criminal
Court |
Other |
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Mental Health: |
(Helps to determine if co-occurring mental health
treatment is necessary) |
DUI SERVICES:
(Services help client get his/her drivers license back
after a DUI) |
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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 |
Spanish |
Consists of twelve 2-hr. sessions. |
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DUI
Outpatient Programs |
6-week
program |
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12-week
program |
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Victims
Impact Panel - Consists of one 2-hr. session, facilitated by (MADD)
Mothers Against Drunk Driving |
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Intensive
Outpatient DUI Programs
- 6 week program (9 hours per
week) and 6-weeks of aftercare.
Individual, group, family
and substance abuse education services provided. |
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Relapse
Prevention/Aftercare Programs-
6-week
DUI Aftercare Program
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COURT RELATED/PROBATION SERVICES: |
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(BADD)- Basic Alcohol/Drug Diversion-
(12 week First
Time Alcohol/Drug Offender Program) |
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(RID)- Reducing Intoxicated Drivers-
(16-24 week
Repeat DUI Offender -Recidivism Reduction Program) |
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(DDDT)- Do Drugs Do Time-
(16-24 week
Repeat Drug Offender -Recidivism Reduction Program) |
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Criminal Thinking
(lmpulse
Control)
Program -
12-24 week
program for adolescents and adults, designed to
challenge and correct irresponsible 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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Johns School- 8 hour
prostitution and solicitation reduction program
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CO-OCCURRING AND SUBSTANCE ABUSE TREATMENT
SERVICES: |
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Substance
Abuse Assessment |
English |
Spanish |
Consists of one 2 ½-hr. session. |
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Early
Intervention Programs- 6-week substance abuse education
program for adults and 12-week substance abuse education
program for adolescents. Random Drug
Testing provided (if UA
referral form completed) |
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Outpatient Adolescent Programs
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6-24 week program for
adolescents.
Individual, group, family and
substance abuse education services provided.
Self-help meeting attendance and random drug testing is
required. |
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Intensive
Outpatient Adolescent Programs
- 12 week program (9-12 hours per
week) and 6-weeks of aftercare.
Individual, group, family
and substance abuse education services provided. Self-help
meeting attendance and random drug testing is
required. |
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Outpatient Adult Programs-
6-24 week program for
adults.
Individual, group, family and
substance abuse education services provided.
Self-help meeting attendance and random drug testing is
required. |
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Intensive
Outpatient Adult Programs
- 12 week program (9-12 hours per
week) and 6-weeks of aftercare.
Individual, group, family
and substance abuse education services provided.
Self-help meeting attendance and random drug testing is
required. |
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Relapse
Prevention/Aftercare Programs |
6-week
program |
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12-week
program |
SPECIALIZED TREATMENT SERVICES: |
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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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Positive Parenting Program -
A “Free”
outpatient program for preganant mothers who have been
or who are struggling with substance abuse presented in a 12 week format with
highly structured, consecutive weekly sessions, each
lasting approximately 1.5 hours.
Areas of focus: nutrition, employment, GED, money
management, vocational training, WIC, infant crisis
services, recovery based services, etc...
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"Amethyst House" (Sober House)
Programs -
90 day to 1 year sober living and outpatient treatment. Individual,
Group, Family and Aftercare Services Provided. Self-help
meeting attendance is required. Random Drug Testing
required.
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Impaired Professionals Program -
12-week to 6 month outpatient treatment set up for
working professionals (attorneys, nurses, doctors and
other professionals who are struggling with addiction
and desire a life of sobriety. Individual, Group,
Family and Aftercare Services Provided. Self-help
meeting attendance is required. Random Drug Testing
required. |
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Opiate Addiction Program - 12-week to 6
month intensive outpatient medication assisted treatment
program set up for individuals who are struggling with
opiate addiction (loritab, heroin, oxycontin, oxycodone,
etc). Individual, Group, Family and Aftercare
Services Provided. Medication assistance (Dr.
visits required). Self-help
meeting attendance is required. Random Drug Testing
required. |
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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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