|Date of assessment:|
|Date of Birth:|
|How often did you use each of the following in the last month?||Didn't use||Once a week or less||More than once a week||Most days or more|
|Alcoholic drinks (e.g. beer, wine, spirits, premixes, RTDs):|
|Cannabis (e.g. weed, marijuana, pot, dope, buds):|
Other drugs (e.g. stimulants, hallucinogens, inhalants, sedatives, synthetic cannabinoids, opiates):
|Mark one box (on each row), on the basis of how things have been for you over the last month?||Not True||Somewhat True||Certainly True|
|1. I took alcohol or drugs when I was alone.|
|2. I've thought I might be hooked or addicted to alcohol or drugs.|
|3. Most of my free time has been spent getting hold of, taking, or recovering from alcohol or drugs.|
|4. I've wanted to cut down on the amount of alcohol and drugs that I am using.|
|5. My alcohol and drug use has stopped me getting important things done.|
|6. My alcohol or drug use has led to arguments with the people I live with (family, flatmates or caregivers etc.).|
|7. I've had unsafe sex or an unwanted sexual experience when taking alcohol or drugs.|
|8. My performance or attendance at school (or at work) has been affected by my alcohol or drug use.|
|9. I did things that could have got me into serious trouble (stealing, vandalism, violence etc) when using alcohol or drugs.|
|10. I've driven a car while under the influence of alcohol or drugs (or have been driven by someone under the influence).|
|Patient is:||Within Adult Guideline||Above Adult Guideline|
Level of AOD problems could be significant and require further assessment and/or treatment.
Level of AOD problems could be significant and require further assessment. Consider referral.
Level of AOD problems are significant and require further assessment and treatment.
Level of AOD problems is significant and requires further assessment and treatment.
Level of AOD problems are serious and require further assessment and treatment.
For youth AOD services in your area click here.
Please consider confidentiality when making a referral.
Please consider family when making a referral.
|Referral to AOD service discussed and recommended|
Has the young person agreed to this referral?
(Agreement is required)
Are the parents of the young person aware of this referral?
(To allow discretion with contacting the young person)
Form will be saved to the patient's "Forms" in a format suitable for printing and faxing to the DHB.
Form will be saved to the patient's outbox in a format suitable for sending to the DHB.
Form will be saved as an attachment to the consult note in a format suitable for printing and faxing to the DHB.