Microsoft word - sec assessment.doc

PLEASE BE CERTAIN THAT YOU RESPOND ACCURATELY TO ALL THE
QUESTIONS. FAILURE TO DO SO WILL JEOPARDISE YOUR LICENCE
AGREEMENT (SHOULD YOU BE OFFERED ACCOMMODATION AT ST ED’S).
BY SIGNING BELOW YOU ARE STATING THAT YOU UNDERSTAND & ACCEPT
THE ABOVE CONDITION.
Please sign……………………….
ST EDMUNDS CHARITY
RESETTLEMENT PROJECT
ASSESSMENT FORM
July 2009
DATE OF ASSESSMENT………………………. WHAT ARE YOU LIKE WHEN YOU ARE DRUNK? CLIENT DETAILS NAME DO YOU CLAIM HOUSING BENEFIT FOR THIS ADDRESS? REFERRAL SOURCE MARITAL STATUS NEXT OF KIN DETAILS NAME ADDRESS TEL RELATIONSHIP TO YOU FAMILY CIRCUMSTANCES FINANCIAL INFORMATION

NATIONAL INSURANCE No:
PRESENT SOURCE OF INCOME:

DWP

ANY OTHER INCOME

WEEKLY / FORTNIGHTLY / MONTHLY AMOUNT
ARE YOU PAID INTO A BANK A/C, B/S A/C OR P/O A/C?
WHAT IS YOUR PAY DAY?
DO YOU HAVE ANY MONEY STOPPED FROM YOUR BENEFIT(S)?
HOW

HAVE YOU HAD ANY HOUSING BENEFIT RELATED DEBTS IN THE PAST 5 YEARS?
YES / NO PLEASE SIGN TO CONFIRM …………………………………………………….
DO YOU HAVE ANY OUTSTANDING RENT ARREARS WITH ROCHDALE COUNCIL?
DO YOU HAVE ANY OTHER DEBTS?
ARE YOU INVOLVED IN ANY LEGAL PROCEEDINGS?
ARE YOU IN CONTACT WITH ANY OTHER AGENCIES?
e.g. Probation Service


HAVE YOU EVER SERVED A CUSTODIAL SENTENCE? Please give full details.

HAVE YOU EVER BEEN CONVICTED OF ANY OF THE FOLLOWING:-
DRINK DRIVING
DRUNK & DISORDERLY
SHOPLIFTING
GBH
ABH
ANY SEX CRIMES
ARSON
DRUG DEALING
OR ANY OTHER OFFENCES
HAVE YOU ACTUALLY EVER BEEN ACCUSED, BUT NOT CONVICTED, OF ARSON OR A SEX
CRIME? Please give full details.
HEALTH INFORMATION

PRESENT GP

HOW WOULD YOU DESCRIBE YOUR GENERAL PHYSICAL HEALTH?
HAVE YOU HAD ANY OF THE FOLLOWING:-
H.I.V. TEST

IF YES, WHEN WAS THE LAST TEST & WHAT WAS THE RESULT?


DO YOU HAVE ANY CHRONIC MEDICAL CONDITIONS SUCH AS:-
ASTHMA
STOMACH ULCERS
DIABETES
BACK PROBLEMS
SKIN PROBLEMS
OSTEO OR RHEUMATOID ARTHRITIS
HEARING PROBLEMS
SIGHT PROBLEMS

ANY OTHER CHRONIC MEDICAL CONDITIONS?
ARE YOU SEEING A CONSULTANT / ATTENDING HOSPITAL AT PRESENT?
FOR WHAT REASON?
ARE YOU HAVING, OR HAVE YOU EVER HAD, ANY PSYCHIATRIC TREATMENT OR ARE YOU
CURRENTLY SEEING ANY SORT OF MENTAL HEALTH WORKER?

DO YOU SUFFER FROM ANY OF THE FOLLOWING:-

PSYCHOSIS
ANXIETY / PANIC ATTACKS
DEPRESSION
SCHIZOPHRENIA
PARANOIA
SHORT TERM MEMORY LOSS
DO YOU SUFFER FROM ANY MENTAL HEALTH PROBLEM NOT LISTED ABOVE?
IF ‘YES’ PLEASE GIVE DETAILS


ARE YOU ON ANY MEDICATION?
SEC Service Users are free to take Campral on a prescribed basis while on placement with us if they feel this
medication is helpful. SEC Service Users are not permitted to take antabuse or hemenevrin.
NB If any prospective service user states that they are taking naltroxene, please see project manager.
Please list all medication you are currently taking, prescribed or ‘over the counter’.
HAVE YOU EVER MISUSED PRESCRIBED MEDICATION?
IF ‘YES’ WHAT WAS THE MEDICATION & WHEN WAS THE LAST TIME YOU MISUSED IT?
HAVE YOU EVER MISUSED OVER THE COUNTER MEDICATION?
IF ‘YES’ WHAT WAS THE MEDICATION & WHEN WAS THE LAST TIME YOU MISUSED IT?
HAVE YOU EVER TRIED TO HARM YOURSELF?
IF ‘YES’ WHAT DID YOU ATTEMPT & WHEN WAS THE LAST TIME YOU TRIED TO HARM
YOURSELF?
EXAMPLES OF HARM ARE: ASPHYXIATION, CUTTING, BLOOD ‘LETTING’, WALKING IN FRONT
OF MOVING TRAFFIC - BUT PLEASE LIST ANY SELF HARM YOU HAVE ATTEMPTED TOGETHER
WITH THE DATE OF YOUR LAST HARM ATTEMPT.



DRINKING & TREATMENT HISTORY

WHAT AGE WERE YOU WHEN YOU STARTED DRINKING?
WHAT AGE WERE YOU WHEN YOU BECAME DEPENDENT?
WHEN DID YOU LAST HAVE AN ALCOHOLIC DRINK?
HAVE YOU EVER UNDER TAKEN ANY OF THE FOLLOWING DETOX METHODS:-
A HOME MEDICAL DETOX?
IF ‘YES’ HOW MANY & WHAT WAS PRESCRIBED?
WHEN WAS YOUR LAST HOME MEDICAL DETOX?
A HOSPITAL OR CLINIC DETOX?
IF ‘YES’ HOW MANY?
WHEN WAS YOUR LAST HOSPITAL / CLINIC DETOX?
HAVE YOU EVER GONE COLD TURKEY?
IF ‘YES’ HOW MANY TIMES & WHEN WAS THE LAST TIME?
HAVE YOU EVER HAD DT’S AS IN SWEATS & SHAKES?
HAVE YOU EVER HAD DT’S AS IN AUDIO OR VISUAL HALLUCINATIONS - OR BOTH?
HAVE YOU EVER HAD ALCOHOLIC FITS?
HAVE YOU EVER HAD ALCOHOLIC BLACKOUTS
HAVE YOU EVER USED ANY OTHER SUBSTANCES –EVER – SUCH AS:-

HEROIN
ANY OTHER SUBSTANCES WITH DATE(S) OF LAST USE: DRUG USE: HAVE YOU EVER INJECTED ANY DRUGS (INCLUDING, IN THE PAST,
TEMAZEPAM ‘JELLIES’)?
IF YOU ANSWERED ‘YES’ TO THE ABOVE QUESTION DID YOU EVER SHARE ANY OF THE
WORKS (INCLUDING FILTERS & SPOONS)?
PLEASE TELL US ABOUT ANY PROBLEMS YOU ARE EXPERIENCING AT THE PRESENT TIME

DO YOU HAVE ANY CULTURAL / RELIGIOUS NEEDS?

ARE YOU INVOLVED IN ANY OF THE FOLLOWING ON A REGULAR BASIS?

SPORTS / HOBBIES
FURTHER EDUCATION
JOB RETRAINING
VOLUNTARY WORK
SOBRIETY SUPPORT GROUPS
ANYTHING ELSE NOT MENTIONED
RELATIONSHIPS

ARE YOU IN A RELATIONSHIP AT PRESENT?
DOES YOUR PARTNER HAVE A PROBLEM WITH ALCOHOL?
WHO ARE THE PEOPLE CLOSEST TO YOU AT PRESENT?
HOW WOULD YOU DESCRIBE THE ABOVE RELATIONSHIP(S)?


USE OF TIME

WHEN DID YOU LAST WORK?

WHAT WERE YOU EMPLOYED AS?
DO YOU FEEL CONFIDENT IN THE FOLLOWING AREAS?
COOKING
CLEANING
SHOPPING
BUDGETING
WASHING / IRONING
BASIC HOME MAINTENANCE SUCH AS CHANGING A PLUG ETC.
FORM FILLING
DEALING WITH EXTERNAL AGENCIES
BEFORE SIGNING PLEASE TAKE A MOMENT TO READ THROUGH WHAT YOU HAVE TOLD ME
TO ENSURE THAT IT IS ACCURATE

.
SERVICE USER / APPLICANT EMERGENCY ACCOMMODATION DETAILS
SERVICE USER / APPLICANT: .
FLAT NO: . (if applicable)
AT: 87 / 110 (delete as appropriate if applicable)
SHOULD A SITUATION ARISE WHEREBY YOU WERE TO NEED EMERGENCY ACCOMMODATION,
HAVE YOU ANYWHERE TO GO? (i.e. PARENT, FRIEND, PARTNER)
YES / NO (delete as appropriate)
IF “YES” PLEASE GIVE NAME, ADDRESS AND TELEPHONE NUMBER OF PERSON WILLING TO
OFFER EMERGENCY ACCOMODATION:
NAME: .
ADDRESS: .
.
.
.
TELEPHONE NUMBER: .
Signed: . date: .

Source: http://www.host-telecom.co.uk/steds/index_files/SEC%20ASSESSMENT.pdf