PROJECT RESTORE

A Collaborative Diversion Effort Between the Criminal Justice System and ENSO Recovery

Criminal Justice Treatment Referral Form

Instructions

Please complete entire form.
The fields with red asteriks are required.
When you select "Submit" a copy will be stored in the Cloud and you will receive a summary email and you will have an option to download the file in PDF format when you see the submission successful screen.
All Historical Referral Data is stored in the Cloud and can be downloaded into Excel or CSV format upon request for simplifying Referral Reporting.

Date

Time

Referral From

Enter town & Dept.

First Name

Middle Initial/Name

Last Name

Age

Gender

Race

DOB

dd/mm/yyyy

Address

Email Address

City

Phone Number

Please Verify Working Number

Zip Code

Phone Type

None

Mobile

Home

Work

What is Client Requesting (In his/her own words)

Date Last Used

Time Last Used

All Other Drugs Use

Secondary Drugs such as Cocaine, Marijuana, Meth, Benzos

Count all check marks, and place client on the opioid disorder severity scale: Check one.

Opioid Use Score

Mild (2-3 symptoms)

Moderate (4-5 symptoms)

Severe (6 or more symptoms)

Add up your check marks and put a check next to one .

After reviewing your answers to my questions, I am concerned that your use of opioids may be negatively affecting your health and I think it would be in your best interest to stop using opioids. On a scale of zero to ten, with zero meaning you are not ready at all to make a change and ten meaning you are ready to make a change now, how ready are you to stop using opioids now?

Client Answer

Why a (number given) and not a lower number?

What would need to happen for you to go from a (given number) to a higher number?

Are you ready to accept a referral to treatment today?

Yes No

Referral Comments

If If female – are/could you be pregnant

Yes No Maybe

Pregnancy Comments

Motivation Questions

Are you willing to commit to a program that will require you to attend group and individual counselling several times a week for several months?

Are you willing to use medication assisted treatment to stop using opioids?

Are you willing to take drug tests when asked to do so?

Are you willing to submit to medication counts when asked to do so?

Are you willing to submit to a complete physical examination and an interview with a physician who specializes in addiction?

Are you willing to follow the directions of the treating physician

Do you understand that you will have to sign a treatment contract, and that if you violate that contract you may be removed from the treatment program?

AGREEMENT EXECUTION INSTRUCTIONS

1. Please fill in Client's Printed Name & Law Enforcement/Court Officer Printed Name
2. Please fill in Date form completed and signed
3, Submit Form
4. Successful Submission screen will have a Download PDF Link
5. Download, Save and Pr
6. Both Client and Law Enforcement/Court Officer Need to sign document.

Client Signature
I, _______________________________________ waive my right to privacy and give permission to Officers of the referring Court to provide the information contained in this survey to one of the County 's community treatment partners for the purpose of evaluation and consideration for entering into an evidence-based, medication-assisted treatment program for opioid addiction. I understand that the community treatment partner, and not the referral source will make the final decision as to whether or not I am accepted into a treatment program. _____________________________________ Client’s Printed Name _____________________________________ Clients Signature Date _____________

Court Officer Signature
The information in this document will be maintained by the County Judicial System and subject to disclosure only as allowed by MRS Title 16, (3)(9) § 631 and §632. This information will only be shared outside of law enforcement for the purpose of obtaining and facilitating the specified treatment for opioid addiction. ______________________________________ Court/Law Enforcement Officer Printed Name _____________________________________ Court/Law Enforcement Officer Signature Date: ___________

PROJECT RESTORE

Criminal Justice Treatment Referral Form

Instructions

Indicate which, if any, of the following have been present during the past 12 month period.

Count all check marks, and place client on the opioid disorder severity scale: Check one.

AGREEMENT EXECUTION INSTRUCTIONS

This form is the property of ENSO, LLC and may not be copied or reproduced without permission of ENSO, LLC.