Initial assessment correspondance version 1.4

ASSESSMENT
Applicant Name: ___________________________________________
Date: __ __ / __ __ / __ __ __ __
Notes:
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Application: Approved / Disapproved Details:______________________________________________________ ____________________________________________________________ Estimated Date of Admission: __ __ / __ __ / __ __ __ __ Details:______________________________________________________ ____________________________________________________________ ____________________________________________________________ Initial Assessment Correspondence Version 1.4 1 PERSONAL INFORMATION
Full Name: ______________________________________________________________________ D.O.B: __ __ / __ __ / __ __ __ __ Age: ______________ Contact Details: (m)_____________________________(h)________________________________ Current Address:__________________________________________________________________ Marital Status: Single Married De Facto Separated Divorced Casual Other Specify:__________________________________ Duration of Relationship: __________ months / years .
If the applicant is not married but currently in a relationship, are they prepared to put the relationship on hold whilst they participate in the program? YES / NO No. of Children: __________ Details: _________________________________________________ REFERRAL INFORMATION
How did the Applicant find out about the Transformations Program: (Please tick) Detox Facility Case Worker Hospital Church Mental Health Other (Please Specify):_________________________________________________ Initial Assessment Correspondence Version 1.4 2 ELIGIBILITY ASSESSMENT
Basic Requirements
Have you detoxed from illicit/licit drugs and alcohol for a minimum of 7 days? Have you identified the problem that caused your life to become unmanageable.
Has the Applicant expressed a desire and is motivated to stop using and change their lifestyle.
Are you 18 years of age or older. (Applications from clients aged 16 to 18 years will be assessed on a range of issues including; guardianship; applicant maturity and current composition of Residents). Have you ever been diagnosed with any mental health issues.
Are you able and prepared to pay in advance the Program Fee prior to
entering the Program:
Youth Allowance: $400 + $50 Deposit = $450
Newstart: $450 + $50 Deposit = $500
Disability Support Pension (DSP) $620 + $50 Deposit = $670
Are you eligible for Centrelink payments.
Do you have any major outstanding loans or debts that may affect your ability to pay the Fortnightly Program Fee. Do you agree to comply with Transformations Program Rules and requirements.
Are you in good physical health and able to fulfill the Work component of the Program.
Transformations is a holistic, faith based, Christian Program.
Are you accepting and willing to participate in the Spiritual Component of
the Program?
Initial Assessment Correspondence Version 1.4 3 SUBSTANCE ABUSE HISTORY
Please provide the following details regarding your drug use.
Substance
Days Used Days Used
Last Used
Cannabis
Amphetamines
Benzodiazepines
Solvents
Other (list)
REHABILITATION & INTERVENTION HISTORY
Have you ever participated in a Rehabilitation or Intervention Program before: YES / NO Type of Program
Residential Rehab
Outclient Program
Pharmacotherapy
Needle Exchange
Counselling
Initial Assessment Correspondence Version 1.4 4 Type of Program
12 Step (eg A.A, N.A)
LEGAL HISTORY
Charge/ Offence
Conviction
Do you have any Pending Charges that are currently being dealt with: YES / NO Pending Action
(i.e Court dates & type of hearing etc.) Are you currently on a Court Order or Parole? YES / NO Initial Assessment Correspondence Version 1.4 5 If YES please provide: Type of Order:_________________ Conditions:______________________ ________________________________________________________________________________ MEDICAL HISTORY
Have you ever been diagnosed with any
mental health issues or illnesses?
(including depression & anxiety disorders)
Have you been diagnosed with any life
threatening illnesses?
Do you have any scheduled surgeries
or need any operations in the next 12
Do you have any chronic medical
problems or illnesses that could hinder
your participation in any activity of the
programme?
Do you suffer from any of the following medical problems? YES / NO If YES please provide details: (please select relevant medical problem and provide details) Medical Problem
Treatment Plan
Other Details
Head Injuries
Cardiac Problems
Chronic Pain
Skeletal Injuries
Pregnancy
List details of any other relevant Medical issues? (e.g details for hospital admission etc) ________________________________________________________________________________ Initial Assessment Correspondence Version 1.4 6 ________________________________________________________________________________ MEDICATION DETAILS
Have you recently or previously been prescribed any medication? YES / NO Medication
Prescribed Currently Duration of
Prescribed
Treatment
Details: _________________________________________________________________________ ________________________________________________________________________________ ADDITIONAL INFORMATION
Is there any additional information you should provide that may affect your Assessment? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Initial Assessment Correspondence Version 1.4 7 Initial Assessment Correspondence Version 1.4 8

Source: http://www.transformation.net.au/documents/1/6/Initial%20Assessment%20Correspondance%20Version%201.4.pdf