S.U.S.T.
You have been asked to complete this form to make
sure that you are receiving the kind of support/information you need in
relation to substance use. Please make sure you have a worker with you when you
complete it so that you can get any help you need.
Many young people use different substances legal
and illegal. Most of them will be using without much harm happening to
themselves or others. However, some may be experiencing problems and it is
important they know what help/support is available.
The
information written here will only be shared with other organisations or people
outside of this agency if it would benefit you and if you give your permission
to do so. We would only have to pass information on to other agencies without
your permission if you were at risk of experiencing significant harm. (Please
talk to a worker for further clarification about this).
Every effort
will be made to make sure that you feel okay about the time, place and help
offered to complete this form and discuss these issues so that it can be a
positive experience for you. Please tell someone if you have any worries at
all.
S.U.S.T
Your
name (or initials)
.
Date
of birth
.
..
Have you filled in one of these before? Yes/No
If so please say where and when it
was?
1. Can
you describe any substances you think you have ever used or are currently using
(this includes alcohol and tobacco)?
Please include how often you use them and how much you use.
2. Have
you thought about why you use substances if you do? Is it part of having a good
time with your friends and/or does it help you feel more able to cope with
certain things about your life?
3. Sometimes
young people are affected by their friends or someone in their familys
substance use. If this is true for you,
it may help to talk about it here.
3. What
do you know about the dangers/effects/side effects of the substances you or
your friends are using?
4. Are there any substances youd like to
know more about? If so, what?
5. What
kind of places and times of day/night do you like to use substances?
6. Do you mainly use on your own or with
your friends?
7. How do you use? smoking, drinking,
swallowing, sniffing, injecting?
8. How do you manage to pay for the
substances you use?
9. Do you always know what you are taking?
If so, how?
10. Do
you ever take more than one substance at a time? If so, which substances?
(remember this includes alcohol and tobacco)
11. What problems (if any) do you think your use causes you or others? How does it affect your life?
12. How
do you feel about your substance use? Do you think its fine? Are there things
about it that worry you at all?
13. What
advice/information have you received about substance use before? What did you
find useful and what wasnt helpful?
Thank
you for your time in completing this form.
An
action plan will be written up and agreed between you and your worker.
Name
Referral to YADAS
for more comprehensive assessment needed? Yes/no
If yes, referral accepted
/refused (delete as appropriate)
Advice/information
needed at Tier 1/2 in relation to substance use and associated risk
(detail work
needed, agency/worker to undertake it and timescales)
Support around
associated issues needed ie housing, education, sexual health, offending
behaviour etc.
(detail work
needed, agency/worker to undertake it and timescales)
Sharing
information consent form completed?
.. (please tick)
Signed:
Worker
Agency
YoungPerson(optional)
Date
.
S.U.S.T
Sharing information consent form
This is your opportunity to say what information
can be passed on and to whom. Nothing will be added or changed without your
knowledge or agreement.
I
..give
..of
(young persons name) (workers name)
(name
of agency) permission to share information contained
in S.U.S.T. to the people listed below. If for any reason I change my
mind I will inform the worker. I understand that any possibility of the
agreement being broken will be discussed with me first.
|
Name
(family member, social worker, agency) |
Relationship
to client |
Information
to be shared please specify |
|
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Young
Persons signature
Date:
.
Workers
signature
Date: