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Statutory Referral

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Statutory Agency Referral Information
for Drug Agencies & Clients

Client’s Name: ______________________ Referral Date: _______________

Risk Category/Factors : __________ Safey Issues: _____________

This information aims to assist the statutory agency, drug agencies and the client in defining: counselling/assessment requirements; possible consequences; and feedback needs of the statutory agency.

  1. What are the requirement conditions?
bullet Court order to undertake counselling
bullet Court order to be assessed
bullet Statutory officer ordered counselling
bullet No requirement conditions, however, would help in client’s case
bullet Urinalysis [conducted by: ___________ ] Frequency: [ ________ ]
bullet Relationship of statutory issue to drug use?
bullet Other: ____________________________________________


  1. What are the minimum requirements of the referral?
bullet Attendance for at least one session
bullet Attendance for multiple sessions (please state number or range _____ )
bullet Demonstrates some participation (see definition of Minimum Participation below)
bullet Performs simple, between session home tasks as directed (eg initiates observational or other home task such as self-monitoring, making a plan, telephoning a support person, etc)
bullet Other: ______________________________________________


  1. What are the likely or possible consequences if minimum requirements are not met?


  1. What is the client’s level of motivation to change and willingness to attend and participate? (as assessed by statutory agency staff ) (NB Motivation is related to importance, willingness & confidence)
bullet Client appears to be motivated to change and agrees counselling and/or assessment a good idea
bullet Client does not appear to be motivated to change but has agreed to counselling and/or assessment
bullet Client does not appear to be motivated to change and also seems reluctant to attend counselling and/or assessment
bullet Client has refused to go to counselling but has been ordered to go
bullet Other: ___________________________________________


  1. What minimum information is required by statutory agency?
bullet Attendance
bullet General progress (eg drug use: a. worse; b. same; c. improved)
bullet More specific information (eg reporting on associated criminal behaviour, increase in dose or change to a more harmful substance, associated psycho-social progress, etc)
bullet Other: ______________________________________________


     6. Other comments?



Example of Minimum Participation

bullet Client to attend on time. If group work: client to be attentive (eg facing facilitator & responding when questioned directly)
bullet 1:1 , couple or family counselling: client responds to questioning, provides some input into issues raised
bullet Other: __________________________________________________________________________


Client Signature:………………………. Date:………..…

Staff Signature:………………… ……. Date:……………

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