Protecting Children in Families Affected by Substance Use Disorders

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You are in section: Table of Contents Preface Acknowledgments 1 - Purpose and Overview 2 - The Nature of Substance Use Disorders 3 - How Parental Substance Use Disorders Affect Children 4 - In Home Examination, Screening and Assessment… 5 - Treating Substance Use Disorders 6 - The Role of Child Protective Services… 7 - Child Protective Services and Substance Use Disorder… 8 - Putting It Together: Making the Systems Work for Families Endnotes Appendix A - Glossary of Terms Appendix B - Resource Listings of Selected National Organizations Appendix C - State Telephone Numbers… Appendix D - Diagnostic and Statistical Manual… Appendix E - Commonly Abused Substances Appendix F - Commonly Used Screening Instruments Appendix G - State of Connecticut Department of Children… Appendix H - Memorandums of Understanding Appendix I - Confidentiality and the Release of Substance… Appendix J - Sample Qualified Service Organization Agreement…

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Appendix G
State of Connecticut Department of Children and Families
Substance Abuse Screening and Information Form

Date: ______/______/_______

DCF Worker: _________________________________ Phone: _________________________

DCF Supervisor: ____________________________ Phone: _________________________

Client Name: _________________________________ SAFE #: ________________________

Date client referred to SAFE, if applicable: _________________________________________

This form shall be completed by the social worker upon return to the office. Please check every box either "yes" or "no," as appropriate. If there is any "yes" box checked for questions 1-13, a referral for an evaluation shall be made to Project Safe.

1. Yes No Client appeared to be under the influence of drugs and/or alcohol.

2. Yes No Client showed physical symptoms of trembling, sweating, stomach cramps, or nervousness.

3. Yes No Drug paraphernalia was present in the home, i.e., pipes, charred spoons, foils, blunts, etc.

4. Yes No Evidence of alcohol abuse was present in the home, i.e., excessive number of visible bottles/cans whether empty or not.

5. Yes No There was a report of a positive drug screen at birth for mother and child.

                     List drugs detected: ____________________________________________________

6. Yes No There was an allegation of substance abuse in the CPS report.

7. Yes No The child(ren) reports substance abuse in the home.

                     When? _____________________________________________________________

8. Yes No The client has been in substance abuse treatment.

                     When? ______________________________________________________________

9. Yes No The client has used the following in the last 12 months:

                     Marijuana/Hashish Heroin/Opiates Cocaine/Crack

                     Other drugs: __________________________________________________________

10. Yes No Client shared that he/she has experienced negative consequences from the misuse of alcohol.

                      DWI/DUI Domestic Fights Job Loss Arrests

                      Other: _______________________________________________________________

11. Yes No Client shared he/she has experienced trouble with the law due to the use of alcohol or other drugs.

                      DWI/DUI Domestic Violence Drug Possession Charge

                      Other: ________________________________________________________________

12. Yes No There are adults who may be using drugs and/or misusing alcohol who have regular contact with the client's children.

13. Yes No The client acknowledged medical complications due to the use of substances.

                      ________________________________________________________________

14. Other Comments:

                     ______________________________________________________________________
                     ______________________________________________________________________
                     ______________________________________________________________________

Adapted from Young, N. K., & Gardner, S. L. (2002). Navigating the pathways: Lessons and promising practices in linking alcohol and drug services with child welfare, Technical Assistance Publication (TAP) Series 27, p. 131–132. (SAMHSA Publication No. SMA-02-3639). Rockville, MD: Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.

previous

You are in section: Table of Contents Preface Acknowledgments 1 - Purpose and Overview 2 - The Nature of Substance Use Disorders 3 - How Parental Substance Use Disorders Affect Children 4 - In Home Examination, Screening and Assessment… 5 - Treating Substance Use Disorders 6 - The Role of Child Protective Services… 7 - Child Protective Services and Substance Use Disorder… 8 - Putting It Together: Making the Systems Work for Families Endnotes Appendix A - Glossary of Terms Appendix B - Resource Listings of Selected National Organizations Appendix C - State Telephone Numbers… Appendix D - Diagnostic and Statistical Manual… Appendix E - Commonly Abused Substances Appendix F - Commonly Used Screening Instruments Appendix G - State of Connecticut Department of Children… Appendix H - Memorandums of Understanding Appendix I - Confidentiality and the Release of Substance… Appendix J - Sample Qualified Service Organization Agreement…

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