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Protecting Children in Families Affected by Substance Use Disorders
Office on Child Abuse and Neglect, Children's Bureau., ICF International. |
|Year Published: 2009|
State of Connecticut Department of Children and Families
Substance Abuse Screening and Information Form
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.
8. Yes No The client has been in substance abuse treatment.
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
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
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.
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