Please give brief outline of substance use including quantity, route of use and how often.
If no substance, add more information into notes above
Currently InjectingPreviously InjectedNever InjectedUnknown
YesNoUnknown
Think about risk of harm to self, risk of harm to others, any offences that have included violence, any risk of harm to lone workers? If none write N/A in box
YesNo
YesNoUnsure
If none write N/A in box . Please give Social Worker name and involvement.
YesNo
YesNoUnsure
Include reasons why this is being prescribed and any other relevant information.
YesNo
YesNo
Please indicate issues to be addressed eg: Bereavement, relationships, ACE's
YesNo
Please indicate yes or no and any relevant information in box provided below.Include here support needs and any information in relation to restrictions on contact ie text only or where the client would like appointments (home / office / community)