SAOL Project Programme Referral Form

SAOL Project Programme Referral Form

Referring for:

Aftercare (Drug free) Childcare Community Employment (C.E.) Key-working/ 1-1 Support IC2 HCV Peer to Peer Training Programme Reduce the Use2 RecoverMe Stabilisation Programme

Solas sa SAOL (Domestic violence)BRIO Programme

WHAT IS SAOL?

The SAOL Project is a person-centred, community-based day programme for women intreatment for drug addiction. Its C.E. programme aims to create positive, meaningful change through an integrated programme of education, rehabilitation, advocacy, childcare provision (with a focus on early childhood education), progression and aftercare supports.

Details of each of the programmes that you can refer your applicant to are available on the website (saolproject.ie); our main programmes are Community Employment (CE), Aftercare programmes (for both ‘drug free’ and ‘stabilising’), BRIO (a new peer training programme for women with addiction and criminality in her history),IC2 Peer to Peer Education and Training, Reduce the Use2, RecoverMe, Individual Support and/or Childcare. You can tick more than one box should you wish to refer your applicant to more than one programme.

Please note that if you are referring your applicant to a CE programme, you will need to complete the accompanying DSP form. This form can be downloaded from the SAOL website.

This form will be responded to as quickly as we can, with people being called for interview in turn (based on date of receiving the form); we attempt to make contact with people within one working week of receiving your referral. To assist us, please ensure that current contact details are fully filled-in. We may contact you at this time to give us any clarifications/additional information that might be relevant to the referral.

PLEASE RETURNTHIS REFERRAL FORM TO:
BY POST: SAOL Project

58 Amiens Street

Dublin 1

D01 K253

BY FAX: (01) 8558934 (PLEASE NOTE OUR FAX NUMBER HAS CHANGED RECENTLY)

BY EMAIL:

1Applicant Information

1.1Applicant Name______

1.2Current Address______

______

1.3Date of Birth / /

1.4Current Telephone No:______1.5 PPS No ______

1.6Is theapplicant aware of this referral?YesNo

2. Referrer Information

2.1Referrer Name______

2.2Position held______

2.3Referral Agency______

2.4Address______

______

2.5Contact No.______

2.6How long have you known the applicant?______

2.7How long more will you be working with this applicant? ______

2.8 Is theapplicant is currently attending an opioid replacement therapy programme?

YesNo

3. ApplicantTreatment Profile

If theapplicant is being referred to the ‘Drug Free’ Aftercare programme, please ignore question 3.1 to 3.3. SAOL accepts people on ‘Drug Free’ Aftercare who are stable on other prescribed medication.

3.1Where does theapplicant attend for drug treatment?______

3.2How many times per week does theapplicant attend for their drug treatment? ______

3.3Has theapplicant attended consistently over the last six months?YesNo

3.4What other medication, including benzodiazepines, is theapplicant currently prescribed? (If not known, please tick box)

MedicationDaily Dosage

______Not known

3.5Name of prescribing doctor(s) ______

3.6Name of counsellor (if any)______

Name of other Key workers(if any)______

Name of other significant case workers (e.g. Probation Officer, Social Worker…)

______

3. Mental Illnesses Section

Please fill in as much details as you are aware of. In this section we are asking if you would distinguish between 3.7a whether or not the applicant is currently treated for a mental illness. 3.7c and if you could then provide any information as to if the applicant has ever been diagnosed with a mental illness.

3.7aIs theapplicantcurrently being treated fora psychiatric illness that we should be aware of?

Diagnosed Medication and Daily Dosage (if applicable)

Depression YesNoDon’t Know

Anxiety YesNoDon’t Know

SchizophreniaYesNo Don’t Know

Bi-polarYesNo Don’t Know

Other: ______

3.7bIf yes, what is the name of the psychiatrist treating the applicant?______

Mental health services address and contact details?______

______

3.7cHas theapplicantever been diagnosed with a psychiatric illness that we should be aware of?

Diagnosed

Depression YesNoDon’t KnowDate when treatment ended: ______

Anxiety YesNoDon’t KnowDate when treatment ended: ______

SchizophreniaYesNo Don’t Know Date when treatment ended: ______

Bi-polarYesNo Don’t Know Date when treatment ended: ______

Other: ______Date when treatment ended: ______

Are there any details about previous psychiatric illnesses that we should be aware of?

______

Are there any other details regarding the applicants current psychiatric illnesses that we should be aware of?

______

3.8Are you aware of any circumstances which could hinder theapplicant’s full participation in SAOL?

YesNo

Please Explain______

______

3.9Do any of the services you provide, and that this applicant must attend, collide with the SAOL attendance time of 9.30 a.m. – 1.30 p.m. Monday to Friday?

YesNo

Please explain______

______

3.10(a)Has theapplicant linked in with any other relevant support services or agencies?

YesNo

Please describe______

______

3.10 (b)Is theapplicant used to working in group settings?

YesNo

Please give further details:

______

SAOL operates a service called ‘SAOL Beag’, a children’s centre for pre-school children who are one year of age or older. SAOL also operates a ‘Summer School’ for older children (up to age 10) during school breaks. These services provide childcare for participants during class-time and also engage with children in an age-appropriate way as applicants in their own right.

3.11Does theapplicant have any children that will be likely to avail of these services? If so, can you give us some details, including ages of the children?

______

3.12Is there any additional information you would like to offer about theapplicant?

______

3.13Any other comments?

______

4Applicant’sDrug Use

Please answer, based on your knowledge and perhapsalso drug screening results, each of the following questions. SAOL is nota drug free service, so answering ‘yes’ to questions below will not block theapplicant from our services (except the drug free groups, obviously!)

These questions relate to your applicant’s drug use during the last 3 months. To the best of your knowledge:

Has theapplicant used heroin in the last 3 months?Yes No Don’t know

Has theapplicant used cocaine in the last 3 months?Yes No Don’t know Has theapplicant used crack cocaine in the last 3 months? Yes No Don’t know

Has theapplicant used un-prescribed tablets in the last 3 months?Yes No Don’t know

Has theapplicant used cannabis in the last 3 months?Yes No Don’t know

Has theapplicant topped up with methadone in the last 3 months?Yes No Don’t know

Has alcohol been a problem for theapplicantin the last 3 months?Yes No Don’t know

5To The Referrer

6.1Are you prepared, as the referrer, to engage in developing and progressing a care plancentred around theapplicant’s needs and to attend two meetings with the applicant in Year Oneof the SAOL Programme?

YesNo

6.2Please select the most appropriate statement below regarding this referral

I highly recommend thisapplicant as suitable for the SAOLprogramme(s) ticked on the first page of this referral form and am willing to engage in developing a care planwith them.

I am unsure which programme(s) theapplicant is bestfor her in SAOL at the moment but am asking SAOL to assess her suitability for them, in the knowledge that I am willing to engage in developing a care planwith SAOL and them.

Other statement ______

______

Signature of Referrer ______Date______

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