docCentre for Concurrent Disorders
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Centre for Concurrent Disorders
Centre for Concurrent Disorders 255 East 12th Avenue Vancouver, BC V5T 2H1 Phone (604) 255-9843 Fax (604) 251-4579 ATTENTION: HEALTH CARE PROFESSIONAL AND/OR REFERRING SOURCE 1) Please complete both pages of this form in its entirety, as this can speed up our process. 2) Please provide the Client’s full name, current address, phone number, date of birth and PHN. 3) Please print clearly. PLEASE NOTE: ● The Client you would like to refer must currently reside in Vancouver or Richmond ● The Client must have stable housing ● The Client must have both Mental Health and Addiction issues ● If you have any concerns regarding the above, we are available for consultation Please note a referral is not a guarantee that the Client will be accepted by our program. Once the referral form has been received and processed, a CCD Clinician will be contacting the Client within 15 business days for a telephone screening. Centre for Concurrent Disorders 255 East 12th Avenue Vancouver, BC V5T 2H1 Phone (604) 255-9843 Fax (604) 251-4579 BEFORE COMPLETING THIS FORM, PLEASE NOTE: You must: (1) live in Vancouver or Richmond, (2) have stable housing, (3) have both mental health & addiction issues. Professional Referral Name of Professional _____________________________________________ Organization ____________________________________________________ Phone _________________________________________________________ Personal Health # Surname DOB (dd.mm.yyyy) Date of Referral (dd.mm.yyyy) Sex : First Name Address Self Referral M F TG Preferred Name Postal Code Home Phone Email Address Cell Phone Family Doctor/Clinic Physician Phone Alcohol & Drug and/or Mental Health Counsellor Current Mental Health Concerns Anxiety Depression Racing Thoughts Paranoia Compulsive Behaviours Suicidal/Self-Harm Thoughts Trouble Concentrating Unstable Relationships Trauma Sudden Emotional Changes Substance Use History Alcohol Marijuana Cocaine Crack Heroin Crystal Meth Ecstasy Mis-Use of Other Prescription Drugs GHB Illicit Methadone Date Last Used: _________________ Current Drug of Choice __________________________ Currently on Methadone? Yes No Allergies: Yes No Significant Medical Issues Risk Factors – Suicide Aggressive Behaviour Self-Harm Behaviour Brain/Head Injury Current Current Current Yes Past Past Past No None None None Parenting Have children under 12 years of age living with you Yes No Have children under 19 years of age living with me Have children under 19 years of age in care of others Have children under 19 years of age with me and in care Criminal Justice No Involvement Have been arrested, not in custody, awaiting trial Convicted, serving Court Order Past Involvement Living Situation Alone Foster Family Group Setting Other Family Other Non-Family Partner/Spouse Partner/Spouse & Family Partner/Spouse & Other Unknown With Child With Parent Living Arrangement Aboriginal Housing Apartment Owned Apartment Rented Assisted Living Basement Suite Facility – Addictions Facility – Mental Health Foster Home Group Home Homeless Hostel Hotel House Owned House Rented No Fixed Address S.I.L. Shelter Single Room Occupancy Transition Home Unknown Treatment History Never had psychiatric hospitalization Hospitalized 1-3 times Hospitalized > 4 times Never had a psychiatric diagnosis Have a psychiatric diagnosis Addiction History I have attended: Detox Daytox Residential Treatment Three Bridges Matrix Program (VAMP) 12 Step Groups SMART, LifeRing groups, etc. Addiction Services Counselling/Groups Number of times you have tried to quit substances: None – my first attempt A few times Over 5 times Longest period of being abstinent (sober or clean): Never Less than 2-3 month Less than 1 year 1-3 years 4-10 years Over 10 years Reason for Ending Last Service or Program: Completed program or made enough progress My substance use increased and I lost focus on the program My mental illness worsened Stop participating because of other factors (e.g. crises, housing, etc) Didn’t like aspects of program or service (e.g. not helpful, disrespect, attitudes of staff, etc) Did get the results I wanted Other reason _____________________________________________________
