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Initial assessment correspondance version 1.4
ASSESSMENT Applicant Name: ___________________________________________ Date: __ __ / __ __ / __ __ __ __ Notes: _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________
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 ChurchMental 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
CENTRO COCHRANE DO BRASIL ACUPUNTURA PARA SÍNDROME DO TÚNEL DO CARPO SÃO PAULO TÌTULO: ACUPUNTURA PARA SÍNDROME DO TÚNEL DO CARPO PERGUNTA A acupuntura é mais efetiva do que o placebo no tratamento da síndrome do túnel do carpo. Introdução: Os sinais e sintomas da compressão do nervo mediano no punho foram inicialmente denominados de neurite do mediano, neuropat
Dr Amal Beaini, Clinical Lead Dr Noufel Aljushaah, Medical Officer June 2011 • 1996: The first patient successfuly completed the compressed opiate detoxification programme. • 2000: Our peer reviewed paper gets published in • 2004: Extended services become available for those patients with concomitant addictions or underlying mental health problems. • 2006: Channel 4 series “