SAOL Project Programme Referral Form
Referring for: (Please feel free to tick more than one category)
After-Care (Stabilisation)
Aftercare (Drug free)
Childcare
Community Employment (C.E.)
Key-working/ 1-1 Support
IC2 HCV Peer to Peer Training Programme
Reduce the Use 2
RecoverMe
Solas sa SAOL
BRIO Programme
WHAT IS SAOL?
The SAOL Project is a person-centred, community-based day programme for women in treatment for drug
addiction. Its C.E. programme aims to create positive, meaningful change through an integrated programme of
education, rehabilitation, advocacy, childcare provision (with a focus on early childhood education),
progression and aftercare supports.
Details of each of the programmes that you can refer your applicant to are available on the website
(saolproject.ie); our main programmes are Community Employment (CE), Aftercare programmes (for both
‘drug free’ and ‘stabilising’), BRIO (a new peer training programme for women with addiction and criminality in
her history), IC2 Peer to Peer Education and Training, Reduce the Use2, RecoverMe, Individual Support
and/or Childcare. You can tick more than one box should you wish to refer your applicant to more than one
programme.
Please note that if you are referring your applicant to a CE programme, you will need to complete the
accompanying DSP form. This form can be downloaded from the SAOL website.
This form will be responded to as quickly as we can, with people being called for interview in turn (based on
date of receiving the form); we attempt to make contact with people within one working week of receiving your
referral. To assist us, please ensure that current contact details are fully filled-in. We may contact you at this
time to give us any clarifications/additional information that might be relevant to the referral.
PLEASE RETURN THIS REFERRAL FORM TO:
BY POST:
SAOL Project
58 Amiens Street
Dublin 1
D01 K253
BY FAX:
(01) 8553395
BY EMAIL:
[email protected]
Telephone:
00 353 1 855 3391/3
Version: May 2016 Page 1 of 6
1
Applicant Information
1.1
Applicant Name ____________________________________________________________________
1.2
Current Address____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
1.3
Date of Birth
/
/
1.4
Current Telephone No:___________________ 1.5 PPS No
1.6
Is the applicant aware of this referral?
Yes
___________________________
No
2. Referrer Information
2.1 Referrer Name
___________________________________________________________________
2.2 Position held
___________________________________________________________________
2.3 Referral Agency
___________________________________________________________________
2.4 Address
___________________________________________________________________
___________________________________________________________________
2.5 Contact No.
___________________________________________________________________
2.6 How long have you known the applicant?
_____________________________________________________
2.7 How long more will you be working with this applicant?
_____________________________________________________
2.8 Is the applicant is currently attending an opioid replacement therapy programme?
Yes
No
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3. Applicant Treatment Profile
If the applicant is being referred to the ‘Drug Free’ Aftercare programme, please ignore
question 3.1 to 3.3. SAOL accepts people on ‘Drug Free’ Aftercare who are stable on
other prescribed medication.
3.1 Where does the applicant attend for drug treatment? __________________________________________
3.2 How many times per week does the applicant attend for their drug treatment? ______________________
3.3 Has the applicant attended consistently over the last six months?
Yes
No
3.4 What other medication, is the applicant currently prescribed? (If not known, please tick box)
Medication
Daily Dosage
_________________________________________
_______________________
Not known
_________________________________________
_______________________
Not known
_________________________________________
_______________________
Not known
_________________________________________
_______________________
Not known
_________________________________________
_______________________
Not known
_________________________________________
_______________________
Not known
3.5 Name of prescribing doctor(s) _________________________________________________________
3.6
Name of counsellor (if any)
___________________________________________________________
Name of other Key workers (if any)
___________________________________________________________
Name of other significant case workers (e.g. Probation Officer, Social Worker…)
___________________________________________________________
3.7a Is the applicant currently being treated for a psychiatric illness that we should be aware of?
Diagnosed
Depression
Anxiety
Schizophrenia
Bi-polar
Other:
Medication and Daily Dosage (if applicable)
Yes
No
Don’t Know
Yes
No
Don’t Know
Yes
No
Don’t Know
Yes
No
Don’t Know
_______________________
3.7b If yes, what is the name of the psychiatrist treating the applicant?
________________________________________________
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3.7c Has the applicant ever been diagnosed with a psychiatric illness that we should be aware of?
Diagnosed
Depression
Anxiety
Schizophrenia
Bi-polar
Other:
Yes
No
Don’t Know
Yes
No
Don’t Know
Yes
No
Don’t Know
Yes
No
Don’t Know
_______________________
Date when treatment ended: ______________________
Date when treatment ended: ______________________
Date when treatment ended: ______________________
Date when treatment ended: ______________________
Date when treatment ended: ______________________
Are there any details about previous psychiatric illnesses that we should be aware of?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
3.8 Are you aware of any circumstances which could hinder the applicant’s full participation in SAOL?
Yes
No
Please Explain ________________________________________________________________________
________________________________________________________________________
3.9 Do any of the services you provide, and that this applicant must attend, collide with the SAOL attendance
time of 9.30 a.m. – 1.30 p.m. Monday to Friday?
Yes
No
Please explain ________________________________________________________________________
________________________________________________________________________
3.10 (a) Has the applicant linked in with any other relevant support services or agencies?
Yes
No
Please describe ________________________________________________________________________
________________________________________________________________________
3.10 (b) Is the applicant used to working in group settings?
Yes
No
Please give further details:
__________________________________________________________________________
__________________________________________________________________________
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SAOL operates a service called ‘SAOL Beag’, a children’s centre for pre-school children who are one year of
age or older. SAOL also operates a ‘Summer School’ for older children (up to age 10) during school breaks.
These services provide childcare for participants during class-time and also engage with children in an ageappropriate way as applicants in their own right.
3.11 Does the applicant have any children that will be likely to avail of these services? If so, can you give us
some details, including ages of the children?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
3.12 Is there any additional information you would like to offer about the applicant?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
3.13 Any other comments?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Version: May 2016 Page 5 of 6
4
Applicant’s Drug Use
Please answer, based on your knowledge and perhaps also drug screening results, each of the following
questions. SAOL is not a drug free service, so answering ‘yes’ to questions below will not block the applicant
from our services (except the drug free groups, obviously!)
These questions relate to your applicant’s drug use during the last 3 months. To the best of your
knowledge:
Has the applicant used heroin in the last 3 months?
Yes
No
Don’t know
Has the applicant used cocaine in the last 3 months?
Yes
No
Don’t know
Has the applicant used crack cocaine in the last 3 months?
Yes
No
Don’t know
Has the applicant used un-prescribed tablets in the last 3 months?
Yes
No
Don’t know
Has the applicant used cannabis in the last 3 months?
Yes
No
Don’t know
Has the applicant topped up with methadone in the last 3 months?
Yes
No
Don’t know
Has alcohol been a problem for the applicant in the last 3 months?
Yes
No
Don’t know
5
To the Referrer
6.1 Are you prepared, as the referrer, to engage in developing and progressing a care plan centred around the
applicant’s needs and to attend two meetings with the applicant in Year One of the SAOL Programme?
Yes
No
6.2 Please select the most appropriate statement below regarding this referral
I highly recommend this applicant as suitable for the SAOL programme(s) ticked on the first page of
this referral form and am willing to engage in developing a care plan with them.
I am unsure which programme(s) the applicant is best for her in SAOL at the moment but am asking
SAOL to assess her suitability for them, in the knowledge that I am willing to engage in developing a
care plan with SAOL and them.
Other statement ___________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Signature of Referrer __________________________________
Date
______________________
Version: May 2016 Page 6 of 6