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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