Statutory
Agency Referral Information
for Drug Agencies & Clients
Client’s Name: ______________________ Referral Date: _______________
Risk Category/Factors : __________ Safey Issues: _____________
This information aims to assist the statutory agency, drug agencies and the client in
defining: counselling/assessment requirements; possible
consequences; and feedback needs of the statutory agency.
What are the requirement conditions?
 |
| Court order to undertake
counselling
|
|
| Court order to be assessed
|
|
| Statutory officer ordered
counselling
|
|
| No requirement conditions,
however, would help in client’s case
|
|
| Urinalysis [conducted by:
___________ ] Frequency: [ ________ ]
|
|
| Relationship of statutory issue to
drug use?
|
|
| Other:
____________________________________________
|
What are the minimum requirements of the referral?
|
| Attendance for at least one
session
|
|
| Attendance for multiple sessions
(please state number or range _____ )
|
|
| Demonstrates some participation
(see definition of Minimum Participation below)
|
|
| Performs simple, between session
home tasks as directed (eg initiates observational or other home task such as
self-monitoring, making a plan, telephoning a support person, etc)
|
|
| Other:
______________________________________________
|
What are the likely or possible consequences if minimum requirements are not met?
What is the client’s level of motivation to change and willingness to attend and
participate? (as assessed by statutory agency staff ) (NB Motivation is related to
importance, willingness & confidence)
|
| Client appears to be motivated to
change and agrees counselling and/or assessment a good idea
|
|
| Client does not appear to be
motivated to change but has agreed to counselling and/or assessment
|
|
| Client does not appear to be
motivated to change and also seems reluctant to attend counselling and/or assessment
|
|
| Client has refused to go to
counselling but has been ordered to go
|
|
| Other:
___________________________________________
|
What minimum information is required by statutory agency?
|
| Attendance
|
|
| General progress (eg drug use: a.
worse; b. same; c. improved)
|
|
| More specific information (eg
reporting on associated criminal behaviour, increase in dose or change to a more harmful
substance, associated psycho-social progress, etc)
|
|
| Other:
______________________________________________
|
6. Other comments?
Example of Minimum Participation
|
| Client to attend on time. If group work: client
to be attentive (eg facing facilitator & responding when questioned directly)
|
|
| 1:1 , couple or family counselling: client
responds to questioning, provides some input into issues raised
|
|
| Other:
__________________________________________________________________________
|
Client Signature:……………………….
Date:………..…
Staff Signature:………………… …….
Date:……………
|
