Medway River Community Assessment Tool

Community Assessment Tool

CDS-R 2024-25
Document Title
Email Address Sender FT
Date assessment completed*

DayMonthYear
Date
Completed by keyworker*

First NameLast Name
Keyworker email address*
firstname.surname@forwardtrust.org.uk

REFERRAL INFORMATION
Consent to NDTMS*
Referral date*

DayMonthYear
Referral source*
Local Referral agency name

DEMOGRAPHICS
Illy Reference
Full name*

First NameLast Name
Stated Sex*
What is the client self-declared gender?*

MaleFemaleTransgenderNon-binaryNot KnownNot StatedOther
Date of birth*

DayMonthYear
National insurance number
NHS number
Ethnicity*
Country of birth*
Preferred language *
Religion*
Marital status*
Stated sexual orientation*
Does {fullName} need support with reading and/or writing?*

IPS - INDIVIDUAL PLACEMENT SUPPORT
Is {fullName} participating in IPS?*

YesNo
Does the client agree to a referral to IPS?*

YesNo
Is {fullName} giving consent to share their data with the IPS scheme*

YesNo
Full postcode for IPS?*
National Insurance Number*

CONTACT INFORMATION
Current housing situation*
No home breakdown*
Renting breakdown*
Other breakdown*
Accommodation type*
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Local authority *
Is {fullName} threatened with homelessness in the next 56 days (8 weeks)?*

YesNo
Email
example@example.com
Phone number 1
Phone number 2
Can a message be left on the provided number

YesNo

ADDITIONAL CONTACT INFORMATION

EMERGENCY CONTACT DETAILS
Next of Kin Name

First NameLast Name
Next of Kin Relationship
Phone number
Next of Kin Address

Street Address

Street Address Line 2

TownCounty

Post Code
Consent to contact

PARENTAL ASSESSMENT
Do you live with other people?
Who do you live with?
Do you have children?
How often do you see them?
Do you have contact with any other children?
Please detail...
Are social services involved?

CHILD DETAILS

Child A
Name

First NameLast Name
Date of birth

DayMonthYear
Does the child live at the clients address?
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Gender
Relationship
GP Surgery
School / Nursery

Child B
Name

First NameLast Name
Date of birth

DayMonthYear
Does the child live at the clients address?
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Gender
Relationship
GP Surgery
School / Nursery

Child C
Name

First NameLast Name
Date of birth

DayMonthYear
Does the child live at the clients address?
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Gender
Relationship
GP Surgery
School / Nursery

Child D
Name

First NameLast Name
Date of birth

DayMonthYear
Does the child live at the clients address?
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Gender
Relationship
GP Surgery
School / Nursery

Child E
Name

First NameLast Name
Date of birth

DayMonthYear
Does the child live at the clients address?
Address

Street Address

Street Address Line 2

TownCounty

Post Code
Gender
Relationship
GP Surgery
School / Nursery

PROFESSIONALS WORKING WITH CHILDREN

Child A
Child protection plan
Details
Child in need plan
Details
Looked after by local authority
Details
Family intensive support process
Details
TAC in place?
Details
Substance misuse related?
Details

Child B
Child protection plan
Details
Child in need plan
Details
Looked after by local authority
Details
Family intensive support process
Details
TAC in place?
Details
Substance misuse related?
Details

Child C
Child protection plan
Details
Child in need plan
Details
Looked after by local authority
Details
Family intensive support process
Details
TAC in place?
Details
Substance misuse related?
Details

Child D
Child protection plan
Details
Child in need plan
Details
Looked after by local authority
Details
Family intensive support process
Details
TAC in place?
Details
Substance misuse related?
Details

Child E
Child protection plan
Details
Child in need plan
Details
Looked after by local authority
Details
Family intensive support process
Details
TAC in place?
Details
Substance misuse related?
Details

PARENTAL ASSESSMENT
Where do you keep drugs / alcohol?*
Could your children have access to them?*
Does anyone in your household use needles?*
Where do you keep them (used and new)?*
How do you dispose of them?*
Where do you keep other paraphernalia?*
How do you dispose of paraphernalia?*
Are there any other adults in your household?*
Do they use any substances?*
Known substances used by other in household.
Who comes in and out of your home?*
What other significant adults do your child/children have in their lives?*
Where are your children when you use drugs / alcohol?*
How do you make decisions about what you spend your money on?*
Would you say your children were aware of your substance misuse?*
How would you say your substance misuse affects your parenting ability?*
Does your substance misuse affects plans you make with your children?*
Do your children attend school / nursery regularly?*

SPECIALIST SUBSTANCE MISUSE TREATMENT HISTORY
Have you ever been previously treated for your substance misuse?*

Click to add treatment history.
Date

DayMonthYear
Interventions
Location of treatment
Current or date left treatment

DayMonthYear
Reason for leaving treatment

Click to add treatment history.
Date

DayMonthYear
Interventions
Location of treatment
Current or date left treatment

DayMonthYear
Reason for leaving treatment

DRUG USE

Problem Substance 1
Problem substance 1
Please enter substance name
Age first used*
Frequency*
In the 12 months prior to being referred
Dose*
Per using day
Route*
Impact of substance use*

Problem Substance 2
Problem substance 2
Please enter substance name
Age first used
Frequency
In the 12 months prior to being referred
Dose
Per using day
Route
Impact of substance use

Problem Substance 3
Problem substance 3
Please enter substance name
Age first used
Frequency
In the 12 months prior to being referred
Dose
Per using day
Route
Impact of substance use

Other (including NPS)
Problem substance
Please enter substance name
Age first used
Frequency
In the 12 months prior to being referred
Dose
Per using day
Route
Impact of substance use

ALCOHOL USE DISORDERS IDENTIFICATION TEST

AUDIT
Select the answer that applies to each question. The score for each response is displayed next to the response below, add them up and enter the total.
How often do you have a drink containing alcohol?*
How many units of alcohol do you drink on a typical day when you are drinking?*
How often do you have 6 or more units if female, or 8 or more if male, on a single occasion in the last year?*
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you failed to do what was normally expected from you because of your drinking?
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
How often during the last year have you been unable to remember what happened the night before?
Have you or someone else been injured as a result of your drinking?
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?
Total Audit Score (Auto Calculated)
Audit Score Guide (Hazardous)

Total Audit Score of {totalAudit353} indicates that {fullName} is drinking above the reccomended guidelines.
Audit Score Guide (Harmful)

Total Audit Score of {totalAudit353} indicates that {fullName} has some alcohol related problems but is not drinking to dependency levels.
Audit Score Guide (Moderate Dependency)

Total Audit Score of {totalAudit353} indicates that {fullName} is drinking to moderate dependency levels.
Audit Score Guide (Severe Dependency)

Total Audit Score of {totalAudit353} indicates that {fullName} is drinking to severe dependency levels. This level of drinking usually requires an alcohol detoxifcation.

SEVERITY OF ALCOHOL DEPENDENCY QUESTIONNAIRE

SADQ
First of all, recall a recent month when you were drinking heavily in a way, which for you, was fiarly typical of a heavy drinking period.
Month
Please select month
Year
Please select the year
During {month} {year} and during other periods when your drinking was similar, how often did you experience the feelings listed below? Please reply to each statement by selecting the most accurate answer for each question.

These questions are about the physical symptoms that you have experienced first thing in the morning during these typical periods of heavy drinking.

Please answer every question
During a heavy drinking period I wake up feeling sweaty.
During a heavy drinking period my hands shake first thing in the morning.
During a heavy drinking period my whole body shakes violently first thing in the morning if I do not have a drink.
During a heavy drinking period I wake up absolutely drenched in sweat.
The following statements also refer to {month} {year} when your drinking was heavy, and to periods like it.

Please answer every question
During a heavy drinking period I like to have a morning drink.
During a heavy drinking period I gulp my first few morning drinks down as quickly as possible.
During a heavy drinking period I drink in the morning to get rid of the shakes.
During a heavy drinking period I have a very strong craving for a drink when I awaken.
The following statements refer to moods and states of mind you may have experienced first thing in the morning during these periods of heavy drinking.

Please answer every question
When I am drinking heavily I dread waking up in the morning.
During a heavy drinking period I am frightened of meeting people first thing in the morning.
During a heavy drinking period I feel at the edge of despair when I awaken.
During a heavy drinking period I feel very frightened when I awaken.
Again, the following statements refer to {month} {year} and the periods like it.

Please answer every question
During a heavy drinking period I drink more than a quarter of a bottle of spirits per day (4 doubles or 1 bottle of wine or 6 beers).
During a heavy drinking period I drink more than half a bottle of spirits per day (or 2 bottles of wine, or 12 beers).
During a heavy drinking period I drink more than one bottle of spirits per day (or 1 gallon of wine, or 24 beers).
1 gallon = 4.5L
During a heavy drinking period I drink more than two bottles of spirits per day (or 2 gallons of wine, or 48 beers).
2 gallons = 9L
I would start to sweat.
My hands would shake.
My body would shake.
I would be craving for a drink.
SADQ Total Score
SADQ Severity Level

SEVERITY OF DEPENDENCY SCALE

SDS
Drug Used To Record SDS*
This should be the primary drug choice
Did you think your use of {drugUsed} was out of control?*
Did the prospect of missing a fix (or dose) or not chasing make you anxious or worried?*
Did you worry about your use of {drugUsed}?*
Do you wish you could stop?*
How difficult did you find it to stop or go without {drugUsed}?*
Total SDS Score
The SDS is a five-item measure of dependence, altered to suit the type of substance used (Gossop et al, 1995). Each item is scored on a four-point scale from 0-3, giving a range of possible scores from 0-15. Principal Components Analysis shows these five items to form a single factor, and the scale has good internal consistency. Its validity has been demonstrated by high correlations with quantity, frequency, and duration of drug use in heroin, cocaine and amphetamine use. The authors do not recommend any cut-off score, but a score of 7 or more is likely to indicate high dependence and a score of 4 or more is like to indicate medium dependence on the basis of the means and standard deviations of the samples they present.

GAMBLE AWARE SCREENING TOOL

GAST-G
How to do the GAST-G? Select the answer that applies to the first question and, if appropriate, select the answer that applies to the following three questions. The score for each response will be automatically added to the total score box at the bottom.
In the last 12 months have you gambled in a casino, bookmaker, online, at a sports venue, through buying scratch-cards, visiting bingo halls, or other similar activities?*
Thinking about the last 12 months, have you bet more than you could really afford to lose?*
Thinking about the last 12 months, have people criticised your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true?Type a question
Thinking about the last 12 months, have you felt guilty about the way you gamble or what happens when you gamble?*
Total GAST-G Score
In the last 12 months, have you been affected by another person as a result of their gambling in a casino, bookmaker, online, at a sports venue, by buying scratch-cards, visiting arcades or bingo halls, or other similar activities?
Scoring

The PGSI (Problem Gambling Severity Index) short-form was developed from the full 9-item PGSI (Volberg & Williams, 2012). The instrument is formed of three questions from the PGSI where each item is scored on a four-point scale from Never to Almost Always. All of those who score 3 or more, indicate Moderate-risk to Problem Gambler and should complete the GAST-full screen. All of those who score 1 or 2 are identified as an at-risk group and should be offered referral to gambling support through self-help materials. This group should also be offered the option of full screening and should be encouraged to do so, ideally through specialist gambling providers. No further action is required for respondents who score 0.

DRINKING AND SMOKING
Alcohol units per day
Drinking days In last 4 weeks
Smoking status*
Would {fullName} like support to give up or cut down on your tobacco smoking?*
Support offered*

INTERVENTIONS FOR BLOOD BORNE VIRUSES GUIDANCE
Please click on the above icon to view The Forward Trust BBV recording documents.

INTERVENTIONS FOR BLOOD BORNE VIRUSES
Hep B intervention status*
Would the client like to be vaccinated?
Previously Hep B infected?*
Hep C intervention status*
Would the client like to be tested?
Hep C results*
Antibody status
Last Hep C test date*

DayMonthYear
Date the client was last tested for Hep C even if it was prior to this treatment journey.
Hep C PCR (RNA) test status*
Has {fullName} been referred for Hep C treatment?
Date of Hep C treatment referral (mandatory when referral made)

MonthDayYear
Date
Has {fullName} ever been tested for HIV?*
HIV test date*

DayMonthYear
Is {fullName} HIV positive?*
Would {fullName} like to be referred for HIV testing?

RECOVERY PLAN
What does {fullName} want to achieve from treatment? *
If {fullName} was to unexpectedly drop out of treatment, how would {fullName} like us to try and re-engage?

RISK SUMMARY

INTERVENTION MODALITIES
Intervention Setting*
Modality Setting
Psychosocial intervention treatment (structured)*

YesNo
Start Date*

DayMonthYear
Pharmacological intervention treatment (structured)*

YesNo
Start Date*

DayMonthYear
Other prescribing intervention treatment (unstructured)*

YesNo
Start Date*

DayMonthYear
Recovery Support*

YesNo
Start Date*

DayMonthYear

National Drug Treatment Monitoring System

TOPS (Treatment Outcome Profile)
The National Drug Treatment Monitoring System (NDTMS) data helps drug treatment demonstrate the outcomes it achieves for the people it treats and in doing so aids accountability for the money invested in it. NDTMS is a national standard and is applicable to young people and adults within community and secure-setting-based treatment providers.

As part of The Forward Trust assessment framwork, you are now required to complete NDTMS TOP's below.

Alcohol
Week 4*
Week 3*
Week 2*
Week 1*
Average*
Units
Total

Opiates/Opioids (Illicit)
Week 4*
Week 3*
Week 2*
Week 1*
Average*
G
Total

Crack
Week 4*
Week 3*
Week 2*
Week 1*
Average*
G
Total

Cocaine
Week 4*
Week 3*
Week 2*
Week 1*
Average*
G
Total

Amphetamines
Week 4*
Week 3*
Week 2*
Week 1*
Average*
G
Total

Cannabis
Week 4*
Week 3*
Week 2*
Week 1*
Average*
SPLIFFS
Total

Tobacco
Week 4*
Week 3*
Week 2*
Week 1*
Average*
Total

Other Substance
Substance Name
Week 4*
Week 3*
Week 2*
Week 1*
Average*
G
Total

Risk Behaviours
Injected
Week 4*
Week 3*
Week 2*
Week 1*
Total
Injected with a needle or syringe used by somebody else?*
Injected using a spoon, water or filter used by somebody else?*
How often has the client had 6 or more units (alcohol) if female, or 8 or more if male, on a single occasion in the last 28 days?*

Not in last 28 daysOnce in last 28 daysWeekly / most weeksDaily / most days

Health & Social Functioning
Days in paid work
Week 4*
Week 3*
Week 2*
Week 1*
Total
Days in volunteering or unpaid structured work placement.
Week 4*
Week 3*
Week 2*
Week 1*
Total
Days attending college or school
Week 4*
Week 3*
Week 2*
Week 1*
Total
Client’s rating psychological health*
Anxiety, depression, problem emotions and feelings
Client’s rating physical health*
Extent of physical symptoms and bothered by illness
Client’s rating overall quality of life*
For example, able to enjoy life, gets on with family and partner
Acute housing problem?*
Unsuitable housing?*

If 'unsuitable housing' is 'Yes', please select all the reasons that apply below:
Poor condition of accommodation
Location (unsafe)
Location (unsuitable)
Affordability
Overcrowding
Doesn't meet the needs of the individual
At risk of eviction?*

ADDITIONAL RECOVERY WORKER NOTES
Should be Empty:

	Yes	No
Using sterile equipment?
Injecting in risky sites?
Rotating sites?
Injected by others?
Abscesses or lumps?
Infected or painful sites?
Loss of useable sites?
Gangrene?
Other health issues?
Safe disposal of needles?
Knows where to get sterile equipment?
Information on safe disposal?

Community Assessment Tool

REFERRAL INFORMATION

DEMOGRAPHICS

IPS - INDIVIDUAL PLACEMENT SUPPORT

CONTACT INFORMATION

ADDITIONAL CONTACT INFORMATION

CHILDREN INFORMATION

PARENTAL ASSESSMENT

CHILD DETAILS

PROFESSIONALS WORKING WITH CHILDREN

PARENTAL ASSESSMENT

SPECIALIST SUBSTANCE MISUSE TREATMENT HISTORY

DRUG USE

DRUG USE CONT.

ALCOHOL USE DISORDERS IDENTIFICATION TEST

SEVERITY OF ALCOHOL DEPENDENCY QUESTIONNAIRE

SEVERITY OF DEPENDENCY SCALE

GAMBLE AWARE SCREENING TOOL

DRINKING AND SMOKING

INTERVENTIONS FOR BLOOD BORNE VIRUSES GUIDANCE

INTERVENTIONS FOR BLOOD BORNE VIRUSES

PHYSICAL HEALTH

DISABILITY, GENERAL & MENTAL HEALTH

EMPLOYMENT & HISTORY

CRIMINAL JUSTICE

RECOVERY PLAN

RISK SUMMARY

INTERVENTION MODALITIES

National Drug Treatment Monitoring System

Injected

ADDITIONAL RECOVERY WORKER NOTES