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V.O.I.C.EVision Of InvolvementCollaborationEmpowermentTRIAGE ASSESSMENT TOOLGUIDANCE FOR USEThis is the common tool that is used across all adult treatment agencies within the Blackburnwith Darwen DAAT area.The Triage should be completed when the substance misuser first contacts substancemisuse services.The aim of the Triage Assessment is to identify potential interventions and the mostappropriate service to provide this.When completing this document, ENSURE ALL ENTRIES ARE WRITTEN IN A LEGIBLEMANNER. If there are any questions that are not relevant or not applicable, please state thisclearly – DO NOT LEAVE SECTIONS BLANK. If you ask a question and the client is unableto provide the information or declines to answer, PLEASE STATE THIS CLEARLY TORECORD THAT THE QUESTION HAS BEEN ASKED.THE TRIAGE ASSESSMENT SHOULD ALWAYS BE COMPLETED IN CONJUNCTIONWITH THE RISK ASSESSMENTThe sections marked withcan be exported to complete the CAF.Items highlighted in RED BOLD must be completed as part of the NDTMS data requirements.CONFIDENTIALITY STATEMENTThe information discussed within this assessment will be treated as confidential within theparameters set out under Information Sharing. Confidentiality can be breached : To protect children at risk of significant harm.To protect the public from acts of terrorism.As a duty to the Courts.Under the Drug Trafficking Offences Act 1986.To prevent or detect a crime.To ensure the service provides a duty of care in a life-threatening situation (e.g. seriousillness or injury, suicide and self-harming behaviour). This includes when a service usercontinues to drive against medical advice, when unfit to do so. In such circumstancesrelevant information would be disclosed to the medical advisor of the Driver and VehicleLicensing Agency (DVLA).To protect the service provider in a life-threatening situation (e.g. calls to police regardingviolent behaviour).If confidentiality is to be broken every effort will be made to inform you where possible unlessthis would prejudice the outcome of any investigation or criminal proceedings.
INFORMATION SHARINGInformation sharing is important for a number of reasons. By sharing information it helps to:avoid duplication of work, identify potential interventions and the most appropriate service toprovide them, it contributes to providing substance misusers with a “seamless” integratedservice that best meets the needs of the client and it helps to reduce the risk of harm to theservice user and others. Information sharing helps to provide service users with the bestpossible service.As already discussed, this document is a tool that is used across all Blackburn with Darwenadult substance misuse treatment agencies. Therefore the information contained within willbe shared with the following agencies, Greater Manchester West Substance Misuse Service,your General Practitioner, Inward House Projects, Lifeline Project, the Jarman Centre(Needle Exchange and Blood Bourne Virus service), and the THOMAS Project, if it isdeemed your needs would be best met by one of these services. Other agencies, than thoselisted above, may also need to be contacted, in this instance you will be asked to provideadditional written consent for us to share information with them.If there is specific information that you do not wish to be shared then you may withdrawconsent for that specific information. This will be recorded on a supplementary informationsharing form. Your consent to share information is reviewed on a 3 monthly basis.Additionally, anonymous information (information that does not identify you) is shared withthe National Treatment Agency (NTA) for performance monitoring and research purposesaimed at monitoring service levels and quality. The NTA will respect the confidentiality of anyinformation given to them and you will not be identified in any research that is published bythe NTA. If you have any questions about how this information is used, you can contact theNTA though the agency.I have had the confidentiality statement explained to me and I understand thatconfidentiality can be breached as outlined above. I understand that it can bebeneficial for my treatment agency to exchange the information contained in thisassessment with other relevant professionals. If prescribing is indicated, I agree to myGP being contacted for relevant information and understand that my GP will beinformed of any medication prescribed for me by the substance misuse service. Iunderstand and agree that my GP will be asked to supply any information which maybe relevant to my drug/alcohol treatment.Client signature:Print Name:Date:Staff Signature:Print Name:Date:NOTE : ENSURE THE CLIENT IS PROVIDED WITH THE NDTMS INFORMATION SHARING STATEMENT
MONITORING INFORMATIONMONITORING INFORMATIONDAAT : Blackburn with Darwen DAAT (Code : B03B)Primary Care Trust : Blackburn with Darwen (Code : 5CC)Local Authority : Blackburn with Darwen (Code: 00EX)PREVIOUS / CURRENT SUPPORTPREVIOUS / CURRENT SUPPORTHave you EVER received structured treatment for substance misuse ?YESNOIF YES, have you received TREATMENT IN THE PREVIOUS 2 YEARS ?YESNOIF YES – Please Give Details :DATESTYPE OF SUPPORTAGENCYFromToAdvice & informationHarm Reduction Services e.g. NeedleExchange, Hepatitis / HIV PreventionStructured day careCare planned counsellingCommunity prescribingInpatient substance misuse treatmentResidential rehabilitationAftercare / Relapse PreventionServicesSelf Help Groups, e.g. AA, NAAre you CURRENTLY IN TREATMENT elsewhere ?YESNOIF YES – Please Give Details (Include Name of Keyworker, Agency Address and Telephone Numberif known) :NOTE : LIST ALL AGENCIES IF MORE THAN ONE
REFERRAL DETAILSREFERRER DETAILSREFERRER’S NAME :REFERRER’S CONTACT DETAILS :POST CODE :Telephone No :DATE of REFERRAL :Fax No :REFERRAL SOURCESelfGPRelativeHospital (General)Concerned otherA&EDrug service statutoryPsychological ServicesDrug service Non-statutoryPsychiatry servicesCommunity Alcohol TeamCommunity Care AssessmentCLA - Children Looked AfterSyringe ExchangePRU – Pupil Referral Unit and other alternativeeducation provision (e.g. home tuition)Arrest Referral / DIP (Includes Tower, PPO, CourtReferral, Tough Choices & Conditional Cautioning)ConnexionsDRREducation ServiceProbation (Includes ATR & Probation Other)Social ServicesCARAT / PrisonEmployment ServiceSex Worker ProjectOutreachOther (Please State)TRIAGE COMPLETION DETAILSTRIAGE COMPLETED BY :AGENCY CONTACT DETAILS :POST CODE :Telephone No :DATE of TRIAGE :Fax No :
DEMOGRAPHIC INFORMATION / PERSONAL DETAILSCLIENT DETAILSCLIENT REFERENCE NUMBER :FIRST NAME :LAST NAME :PREVIOUS NAME / AKA :GENDER :DATE OF BIRTH :FemaleMaleAge :ADDRESS :How Long Have You Lived at Your Current Address? :POST CODE:WARD AREA :Telephone No :Mobile No :Clients preferred method of contact :NHS No :ETHNICITYWhiteMixedAsian/ Asian BritishWhite & BlackCaribbeanWhite & BlackAfricanBritishIrishOther WhiteBlack/ Black hite & AsianBangladeshiOther BlackNot StatedOther MixedOther AsianIndianNATIONALITYPlease Specify :EMPLOYMENT STATUSMARITAL STATUSRegular EmploymentMarriedPupil/StudentCohabiting / PartnerEconomically InactiveSingleUnemployed (ClaimingBenefits)SeparatedOtherDivorcedNot KnownWidow / WidowerNot KnownRELIGION (Please State)Is English the clients first languageYesNoIf No Please State 1st :INTERPRETER REQUIRED ?YesNoIf Yes please detail :
DEMOGRAPHIC INFORMATION / PERSONAL DETAILS Ctd.PARENTAL STATUSCHILDREN LIVING WITH CLIENTNot a parent1 x child living with clientAll children live with client2 x children living with clientSome of the children live with clientn x children living with clientNone of the children live with clientNo children living with clientClient Declined To AnswerClient Declined To AnswerCHILDCARE RESPONSIBILITIESDo you have any childcare responsibilities – either as a parent or as a carer, e.g. step parent,grandparent, OR regular contact with any children – e.g. partners children visiting the home?Note : If the client has children under the age of 18 living with them or has childcareresponsibilities then :1. Complete the Children Section on the Comprehensive Assessment andcomplete and submit the CAF Assessment as appropriate.2. Ensure you provide information relating to the storage of drugs / medication /alcohol including providing a safe box for storage of drugs / medication.SEXUAL ORIENTATIONPREGNANCYAre you pregnant ?YesHeterosexualNoGayIf Yes Please Give Details e.g. Estimated date ofdelivery etc. :BisexualOtherNot DisclosedCould You be pregnant?Note:YesNoIf the client is pregnant refer to the Drug Liaison Midwife.If the client could be pregnant offer pregnancy test.LIVING WITHDo They Use Drugs /Alcohol?Are They Dependant on You as aCarer?AloneParents / oFriendsYesNoYesNo
DEMOGRAPHIC INFORMATION / PERSONAL DETAILS Ctd.ACCOMODATION STATUSUrgent Housing ProblemLive on Streets (Sleeping Rough)Staying With Friends (Staying with different friends on a night by night basis)Hostel (Night by Night Basis)Housing ProblemSquattingStaying With Friends / Family (Short Term Guest)Hostel (Short Term Stay)Night / Winter ShelterBed & Breakfast / HotelNo Housing ProblemTravellerSettled With Friends / FamilySupported Housing / HostelApproved PremisesPrivate RentedRented : Local Authority or Registered Social LandlordOwner OccupiedG.P. DETAILSNAME :CLINIC ADDRESS:POST CODE:Note:Telephone No:If the client is not registered with a Blackburn with Darwen G.P. commence work to registerclient with a Blackburn with Darwen G.P.EMERGENCY CONTACT DETAILSNAME :ADDRESS:POST CODE:RELATIONSHIP TO CLIENT :Telephone No :Mobile No :
PRESENTING SUBSTANCE MISUSE PROBLEMPRESENTING PROBLEMPrimary Drug onlyPrimary Alcohol onlyPoly Substance Primary drug use secondary alcoholPoly Substance Primary alcohol use secondary drugPoly Substance Primary drug use secondary drugREASONS FOR SEEKING TREATMENTPlease tell us about your reasons for seeking treatment, your current thoughts about yoursubstance misuse risks, concerns etc. and your expectations of treatment and substance misuseservices.Note : It is important to fully inform the client about the aim of the overall Blackburn with Darwentreatment system is for clients to achieve abstinence. Detox should be fully explored as anoption.TREATMENT MODALITY REQUESTED AT ASSESSMENTMODALITYAdvice And InformationAlcohol StructuredPsychosocial InterventionSpecialist PrescribingOutreachOther StructuredInterventionsInpatient TreatmentNeedle ExchangeAlcohol Other StructuredInterventionsAlcohol Inpatient TreatmentStructured Day ProgrammeAlcohol Brief InterventionsResidential RehabilitationAlcohol Structured DayProgrammeGP PrescribingAlcohol ResidentialRehabilitationStructured PsychosocialInterventionAlcohol CommunityPrescribingAftercareOther : Please Specify :Note : indicate all that apply.
ALCOHOLCURRENT DRINKINGDuring The Previous 28 Days On How Many Days Did You Drink?Type of drink and Strength?Average Number Of Units Per Day :Financial Expenditure on Alcohol (Compare to Income)?ALCOHOL AUDIT QUESTIONNAIREPlease TICK your answer to each of the 10 questions1. How often do you have a drink containing alcohol?NeverMonthly or less2 - 4 times permonth2 - 3 times perweek4 per week2. How many drinks containing alcohol do you have on a typical day when you are drinking?1 or 23 or 45 or 67 to 910 or moreWeeklyDaily or almostdaily3. How often do you have six or more drinks on one occasion?Less thanMonthlyNeverMonthly4. How often during the past year have you found that you were not able to stop drinking once youhad started?Less thanMonthlyNeverMonthlyWeeklyDaily or almostdaily5. How often during the past year have you failed to do what was normally expected of you becauseof drinking?Less thanMonthlyNeverMonthlyWeeklyDaily or almostdaily6. How often during the past year have you needed a first drink in the morning to get yourself goingafter a heavy drinking session?Less thanMonthlyNeverMonthlyWeeklyDaily or almostdaily7. How often during the past year have you had a feeling of guilt or remorse after drinking?Less thanMonthlyNeverMonthlyWeeklyDaily or almostdaily8. How often during the past year have you been unable to remember what happened the nightbefore because you had been drinking?Less thanMonthlyNeverScore 0Score 1MonthlyWeeklyScore 2Score 3Daily or almostdailyScore 49. Have you or has someone else been injured as a result of your drinking?NoYes, but not in the past yearYes, during the past year10. Has a relative or friend or a doctor or other health worker been concerned about your drinkingor suggested you cut down?NoYes, but not in the past year02Yes, during the past year4TOTAL SCORE :
DEFINITIONS & ACTIONS1 unit of alcohol is equivalent to : Half-pint regular beer, cider, lagerSmall glass of winePub measure (25ml) of spiritsPub measure (50ml) of fortified wine e.g.sherry, madeira, portHIGHER RISK 1.Is defined as that causing harm to thepsychological or physical wellbeing of theindividual.2. For a score of 16-19 advise your patientto abstain from alcohol. Furtherassessment is advised e.g. physicalexamination, blood tests and assessmentfor dependence.LOW RISK Sensible limits :1. Sensible/low risk limits for men are nomore than 3 units/day or 21 units/week.2. Sensible/low risk limits for women are nomore than 2 units/day or 14 units/week.A score of : 0 - 7Indicates Sensible DrinkingACTION : PRAISE SENSIBLE DRINKING ANDPROVIDE MINIMAL INFORMATION ON THERISKS OF INCREASED ALCOHOL INTAKEHarmful alcohol intakeA score of : 16 -19Indicates Harmful DrinkingACTION : REFER TO EVOLE or GMW FOREXTENDED BRIEF INTERVENTION AND/ORCOMPREHENSIVE ASSESSMENT Dependent alcohol intake1. Is defined as that causing harm to thepsychological or physical wellbeing of theindividual.INCREASING RISK Hazardous alcohol intake1. Is defined as a level of consumption orpattern of drinking which, if it persists, islikely to result in harm. Men regularlydrinking more than 3 units/day (21units/week)andwomenregularlydrinking more than 2 units/day (14 units/week) can be regarded as hazardousdrinkers.2. Binge drinking is also regarded ashazardous to health. Binge drinking canbe defined as drinking over half therecommended number of units of alcoholper week in one session i.e. 10 units formen or 7 units for women3. For a score 8-15 advise your patient tocut down on drinking. Explain the harmexcessive drinking can do, give positivereasons for drinking less and advise onsensible drinking limits. Give leaflet etcA score of : 8 – 15Indicates Hazardous DrinkingACTION : BRIEF INTERVENTION TO BEDELIVERED AT SOURCE OF CONTACTA score of : 20 Indicates Dependent DrinkingACTION : REFER TOASSESSMENTFORDEPENDENCEGMW - REQUIRESSEVERITYOF
DRUGSPLEASE IDENTIFY YOUR FIRST DRUG OF CHOICE:AGE IN YEARS THAT THE CLIENT RECALLS FIRST USING FIRST DRUG OF CHOICE:ROUTE OF ADMINISTRATION FOR FIRST DRUG OF CHOICE :PLEASE IDENTIFY YOUR SECOND DRUG OF CHOICE:PLEASE IDENTIFY YOUR THIRD DRUG OF minesEcstasyCocaineCrack CocaineAnti DepressantsMajor TranquilisersBenzodiazepinesBarbituratesOther OpiatesIllicit MethadoneHeroinPrescription Drugs *Other drugsPlease Specify:* Includes Prescribed MethadoneAge First UsedDate Last UsedDuration of thisepisode of useQuantity/ UnitsWeight / MoneyDailyWeeklyMonthlyOccasionallyFrequency of UseIVSniffSmokedOralSUBSTANCETYPEOtherRoute ofAdministration
PHYSICAL HEALTHCan you please give details regarding your Physical Health (e.g. serious illnesses or operations, drugor alcohol related physical problems, recent attendance at A&E)Are you currently receiving prescribed medication? : YesNoIf Yes please detail :Do you have any allergies? :YesNoYesNoIf Yes please detail :Is Client Registered Disabled? :If Yes please detail :Are there any special needs that need to be considered (e.g. literacy, access to building, cultural)?If Yes please detail :
PHYSICAL HEALTH Ctd.INJECTING BEHAVIOURCURRENTLY INJECTING?YesNoIf YES injected in the past 28 days?YesNoIf YES are you using the Needle / Pharmacy Exchange?YesNoINJECTED PREVIOUSLY BUT NOT CURRENTLYYesNoNEVER INJECTEDYesNoHAVE YOU EVER SHARED?YesNoShared In The Past 28 Days?YesNoIf you have injected in the past 28 days please give details, e.g. do you inject yourself, do youexperience problems when injecting, what injection sites have you used, DVTs etc.?Note : If the client has injected in the past month and is NOT using the Needle / PharmacyExchange then provide information on safer injecting practices and refer the client to theNeedle Exchange.BLOOD BOURNE VIRUSESHEPATITIS B INTERVENTION STATUSPrevious Hep B infected ?YesNoAlready ImmunisedAcquired ImmunityYesIf YES please give details :One vaccinationTwo VaccinationThree VaccinationHave you been vaccinated against Hepatitis B?Course CompletedNoIf NO offer vaccinations (Refer as appropriate)Not OfferedOffered and AcceptedOffered and RefusedAssessed as not appropriate to offer :Please Detail Why:
PHYSICAL HEALTH Ctd.HEPATITIS C INTERVENTION STATUSYesNoIf YES please give details: veDate of Last Test:-veIf NO offer vaccinations (Refer as appropriate)Have You Been Tested For Hepatitis C?Not OfferedOffered and AcceptedOffered and RefusedAssessed as not appropriate to offer :Please Detail Why:Have You Been Referred To Hepatology ?YesNoYesNoHIV INTERVENTION STATUSIf YES please give details: ve-veNO If NO offer client test (Refer as appropriate)Have You Been Tested For HIV?Not OfferedOffered and AcceptedOffered and RefusedAssessed as not appropriate to offer :Please Detail Why:STREET SEX WORKARE YOU A SEX WORKERIf YES are you selling sex from premises?If YES are you selling sex from the street?YesNo
MENTAL HEALTHAre you currently involved with any mental health services (e.g. Psychiatry,Community Mental Health Team etc.)?YesNoYesNoYesNoIf Yes Please give details :Are you currently receiving prescribed medication?If Yes Please give details :Do you have any concerns with respect to your psychological / mental health?If Yes Please give details :LEGALLEGAL CIRCUMSTANCESHave you been arrested or released from prison in the previous 4 weeks?YesNoAre you being assessed as a result of a conditional caution?YesNoAre you awaiting trial?YesNoAre you a PPO/on license/on a condition for drug testing?YesNoAre you on a community sentence with condition of treatment (DRR/ATR)?YesNoIF THE ANSWER IS YES TO ANY OF THE ABOVE REFER TO THE CRIMINAL JUSTICE DRUGS TEAMPRECONVICTIONS / DRUG RELATED OFFENDINGHave you any pre-convictions?YesNoHas your previous (current) offending been substance related?YesNoENSURE RISK ASSESSMENT IS COMPLETED
TRIAGE SUMMARY & PLANChecklist (As appropriate)Risk Assessment Completed (All Clients)YesNoYesNoClient provided information on safe storage of medication / drugs / alcoholYesNoClient provided with safe storage boxYesNoYesNoYesNoClient Offered Hep B vaccinations (As necessary)YesNoClient Offered Hep C Test (As necessary)YesNoYesNoIf not please explain why not:CAF & Childcare Section on Comprehensive Assessment Completed (As necessary)If not please explain why not:If not please explain why not:Referral made to Drug Liaison Midwife (As necessary)If not please explain why not:Client Referred to Needle Exchange (As necessary)If not please explain why not:If not please explain why not:Drug Screen taken (As necessary):If not please explain why not:
OutcomeInappropriate referral?YesNoYesNoYesNoYesNoIf Yes, please Give Details:Referred On?Please Give Details:Taken on to caseload?If YES, Summary Action Plan (e.g. modality, start date/ appointment times etc.):IS THIS AGENCY RESPONSIBLE FOR CARE COORDINATION & TOPS
SUPPLEMENTARY INFORMATION SHARINGI give permission to share the information with the agency/person(s) identified as detailed:Specify Agency / PersonContact Details & Telephone NumberInformation to be shared (e.g. Care Plan, Transfer Information) :Any Comments or Specific Instructions:Client Signature:Date:Print NameStaff Signature:Date:Print NameSpecify Agency / PersonContact Details & Telephone NumberInformation to be shared (e.g. Care Plan, Transfer Information) :Any Comments or Specific Instructions:Client Signature:Date:Print NameStaff Signature:Print NameDate:
TRIAGE ASSESSMENT TOOL GUIDANCE FOR USE This is the common tool that is used across all adult treatment agencies within the Blackburn with Darwen DAAT area. The Triage should be completed when the substance misuser first contacts substance misuse services. The aim of the Triage Assessment is to identify potential interventions and the most
