State of New Jersey



State of New Jersey

DEPARTMENT OF HUMAN SERVICES

Division of Child Protection and Permanency

Adolescent Substance Abuse Assessment Referral Form

PART I (Completed by Worker)

Identifying Information

Date referred: ______________ Name of agency:

Address: ___________________________________________________________________________________________________

Current case status (check all that apply): CPS Investigation CWS Assessment Permanency Transfer

Name of adolescent allegedly using or abusing substances: __________________________________________________

Sex: Male Female Birth date: __________Case ID/KC #: _______________Person ID/Member #: __________

Name of Local Office: _________________________ Address: _____________________________________________

Worker: _________________________________________________________Telephone/Ext.: ____________________

Supervisor: ______________________________________________________ Telephone/Ext.: ____________________

Name of health insurance, including Medicaid: _________________________________________ ID #: _____________

Address where adolescent is living: _____________________________________________________________________

Placement? Yes No If placed, what was the date of initial placement? __________________________________

Mother: ______________________________________________________________Telephone: ___________________

Address (if different from adolescent): __________________________________________________________________

Father (if known): ______________________________________________________Telephone: __________________

Address (if different from adolescent): __________________________________________________________________

Name of caregiver(s) or legal guardian(s) (if adolescent not living with parents): _________________________________

Address: ___________________________________________________________________Telephone/Ext.: __________

Temporary Assistance for Needy Families/General Assistance eligible? Yes No TANF/GA #: _________________

Siblings' names/ages: (Check) In-Home: Out-of-Home: Date of initial placement:

1._____________________________________________ ____________________

2._____________________________________________ ____________________

3._____________________________________________ ____________________

4._____________________________________________ ____________________

Education

Name of school currently attending: ___________________________________________________ Grade level: ______

Address: __________________________________________________________________________________________

School contact:_______________________________________________________ Telephone/Ext.:_________________

Adolescent classified? Yes No Classification: ______________ Individualized Education Program? Yes No

Medical

Does the adolescent have any history of violent crimes or psychiatric hospitalization? Yes No

DSMIV Diagnosis Axis I: ____________________________________________________________________________

Is the adolescent taking any medications? Yes No If yes, list type, dosage, and frequency: _________________

__________________________________________________________________________________________________

Court Involved

Is the adolescent court-involved? Yes No Is the treatment court ordered? Yes No If yes, what are the charges/offenses? ___________________________________________________________________________________

Name of adolescent's Probation Officer: ___________________________________________Telephone/Ext: _________

PART II (Completed By Worker and Supervisor)

Reason for Referral

Type(s) of substance(s) reported/alleged and duration of use (select substance(s) from National Institute on Drug Abuse, NIDA, chart which is attached): _________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

Level of cooperation with treatment by adolescent: Poor Fair Good

Has the parent/caregiver/guardian agreed to participate in treatment? Yes No

Availability for appointments: Adolescent: Days: ________________ Evenings: ______________

Parent: Days: ________________ Evenings: _______________

Caregiver/Guardian: Days: ________________ Evenings:_______________

Summary of why adolescent needs substance abuse treatment (relevant to alleged substance use or abuse): ____________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Previous substance abuse treatment history (include agency name and address): ______________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Please provide psychiatric/psychological assessment if completed in the last twelve months.

Check, if reports attached. Identify: _________________________________________________________________

(For transfer cases with no new Worker, Parts I and II are completed by the previous Supervisor.)

PART III (Completed By Gatekeeper/Liaison)

Telephone or in-person conference held with Worker and/or Supervisor regarding the referral? Yes No

Results of Conference: __________________________________________________________________________

PART IV

SIGNATURES:

CP&P Worker: ______________________________________________________________ Date: _______________

CP&P Supervisor: ____________________________________________________________ Date: _______________

For transfer cases: Signature of CP&P assigned Supervisor or Casework Supervisor: ____________________________

___________________________________________________________________________ Date: ________________

CP&P Casework Supervisor: ___________________________________________________ Date: ________________

CP&P Gatekeeper/Liaison: _____________________________________________________ Date: ________________

Treatment Provider Counselor: ______________________________________________Date Received: _____________

Appointment Date and Time:__________________________________________________________________________

COMMONLY ABUSED DRUGS

Visit NIDA at

Substance:

Category and Name Examples of Commercial and Street Names

|Cannabinoids |

|hashish |boom, chronic, gangster, hash, hash oil, hemp |

| | |

|marijuana |blunt, dope, ganja, grass, herb, joints, Mary Jane, pot, reefer, sinsemilla, skunk, weed |

| |

|Depressants |

| |Amytal, Nembutal, Seconal, Phenobarbital: barbs, reds, red birds, phennies, tooies, yellows, yellow jackets |

|barbiturates | |

|benodiazepines (other than | |

|flunitrazepam) | |

| |Ativan, Halcion, Librium, Valium, Xanax: candy, downers, sleeping pills, tranks |

|fluitrazepam *** |Rohypnol: forget-me pill, Mexican Valium, R2, Roche, roofies, roofinol, rope, rophies |

|GHB *** |gamma-hydroxybutyrate: G, Georgia home boy, grievous bodily harm, liquid ecstasy |

|methaqualone |Quaalude, Sopor, Parest: ludes, mandrex, quad, quay |

|*** Associated with sexual assaults |

| |

|Dissociative Anesthetics |

|ketamine |Ketalar SV: cat Valiums, K, Special K, vitamin K |

|PCP and analogs |phencyclidine: angel dust, boat, hog, love boat, peace pill |

| | |

|Hallucinogens |

|LSD |lysergic acid diethylamide: acid, blotter, boomers, cubes, microdot, yellow sunshines |

|mescaline |buttons, cactus, mesc, peyote |

|psilocybin |magic mushroom, purple passion, shrooms |

| | |

|Opioids and Morphine Derivatives |

| |Empirin with Codeine, Fiorinal with Codeine, Robitussin A-C, Tylenol with Codeine: Captain Cody, Cody, schoolboy: (with glutethimide) |

| |doors & fours, loads, pancakes and syrup |

|codeine | |

|fentanyl and fentanyl analogs |Actiq, Duragesic, Sublimaze: Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, Tango and Cash |

|heroin |diacetylmorphine: brown sugar, dope, H, horse, junk, skag, skunk, smack, white horse |

|morphine |Roxanol, Duramorph: M, Miss Emma, monkey, white stuff |

|opium |laudanum, paregoric: big O, black stuff, block, gum, hop |

|oxycodone HCL |OxyContin: Oxy, O.C., killer |

|hydrocodone bitartrate, | |

|acetaminophen | |

| |Vicodin: vike, Watson-387 |

| | |

|Stimulants |

| |Biphetamine, Dexedrine: bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers |

|amphetamine | |

| |Cocaine hydrochloride: blow, bump, c, candy, Charlie, coke, crack flake, rock, snow, toot |

|cocaine | |

| |

|MDMA | |

|(methyl-enedioxymethamph-etamine| |

|) |Adam, clarity, ecstasy, Eve, lover’s speed, peace, STP, X, XTC |

|methamphetamine |Desoxyn: chalk, crank, crystal, fire, glass, go fast, ice, meth, speed |

|methylphenidate | |

|(safe and effective for | |

|treatment of ADHD) | |

| |Ritalin: JIF, MPH, R-ball, Skippy, the smart drug, vitamin Ra |

|nicotine |cigarettes, cigars, smokeless tobacco, snuff, spit tobacco, bidis, chew |

| |

|Other Compounds |

|anabolic steroids |Anadrol, Oxandrin, Durabolin, Depo-Testosterone, Equipoise: roids, juice |

|inhalants |Solvents (paint thinners, gasoline, glues), gases (butane, propane, aerosol propellants, nitrous oxide), nitrites (isoamyl, isobutyl, |

| |cyclohexl): laughing gas, poppers, snappers, whippets |

| | |

|Alcohol |booze, bottle, brewsky, brew, coolers, forty, forty ouncer, hooch, juice, Kool aid, happy juice, pounder, sauce, shooter, shots, sixer,|

| |suds, tea, tonic, White Lightening, vino, cold one, moonshine, Wahoo Juice; |

| |Beer bongs and shotguns are used to get intoxicated quickly |

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