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Name: _____________________Gender:_____ Date Of Birth:____________



Address:       ____________________________________________________





Phone: _____________________ E-mail: _____________________________



Presently living with: _____________________________________________



Legal Guardian: _________________________________________________



2.      Why is referral being made at this time?         






3.        Drug Use and History


Type            Amount      Duration     Age First Used       Frequency      Mode of use            







How was it obtained?                                                        




Longest Period of Abstinence



-- 2 --





Relationship With Parents:



Relationship With Siblings:



Family Substance Abuse:



Parents Style of Discipline:



Family Motivation for Treatment:




Health: (describe any significant health problems or physical impairment)



Prescribed Medication:



Family Doctor:






Present Grade  (or last grade attended): ___________________________


Name of School: _______________________________________________


Academic History:



Behavior in School:



-- 3 --


Work History:





Social Functioning:



Relationship with Peers:






Leisure Activities:





Emotional Functioning: (Depression, suicidal ideation, anger control,

self - esteem, etc.)





Legal/Police Contact:  (Probation, charges pending, etc.)





Current & Previous Therapeutic Contacts:





Client’s Goals at Present:




-- 4 --


Client’s Strengths and Present Resources:






Other Significant Information: (i.e. history of misuse, if known)






Interviewers Impressions and Recommendations:




















Interviewer:        __________________________________________



Date:                  __________________________________________










1)         Build a Relationship - The most fundamental tool in any intervention is your            relationship with the client. This relationship is the vehicle for change.


2)         Family Reenactment - The dynamics involved in your relationship with the adolescent client will be a reenactment of an earlier relationship with a significant        other. What remains unresolved will be given an opportunity to change through a         corrective emotional experience.


3)         Systemic Approach - The adolescent may be acting out through drugs as a way of bringing attention too a situation that is most uncomfortable. The client must not be seen in isolation, as the well - being of others may be at stake.


4)         Activity - The use of joining through some type of activity, i.e.: walking, or small projects create a relaxed atmosphere and interest.


5)         Have Fun! - If counseling adolescents isn’t fun for you, then imagine the client’s      response. The use of jokes, books and photographs provide bases for relationship           building.


6)         Spiritual - Spark discussion around the existence of a higher power. Help the          adolescent develop a sense of self-based on likes, dislikes, philosophies and          interests. Make them accountable for their belief system.


7)         Respect - Adolescents believe that they are always right. Find ways to develop reality testing without getting into a power struggle.


8)         Availability - Adolescents will test to see how much you really care by dropping      in and prolonging appointments. How you set your limits is vital in modeling good relationship skills.


9)         Family Liaison - You will be called between sessions by one or many immediate     and extended family members. Be sure that you do not form triangles or alliances            that may be detrimental to your treatment goals.


10)        Agency Liaison - Be cautious of what you share with other interested friends and agencies that may be involved with the adolescent. The adolescent believes that   your relationship is special and they judge this by what gets back to them.














All adolescents participating in program are encouraged to attend this meeting. It is the pivotal component of Youth Support and incorporates the philosophy of self-help and a sense of belonging. It must be a safe place for the recovering young person.


The group is facilitated by a staff person and must not be allowed to function without direction. It must function in a manner which respects the worth and dignity of each participant.




























The Parent Support Group is facilitated by a staff person or designated volunteer and is primarily a self - help directed program with the following goals:











·         Through group discussion, further access and deal with any complicating dysfunction in family members and the adolescent such as: eating disorders, relationship problems, compulsive shopping, gambling, compulsive lying, smoking, unprotected sex and attempt to motivate those involved towards a healthier lifestyle change.




















Adolescent detoxification differs from that of adults in that the severity of withdrawal is not as severe, in most cases. The primary goal for most adolescents is to break the use cycle, thus enabling the client and staff to begin counseling / therapy in a safe environment, away from a domain where the pressure to use is often overwhelming. The time in the Detoxification Unit also provides a ‘cooling off’ period for both adolescent and parents, enabling staff to initiate a treatment process for family members.



Referral Process


Referrals of adolescents may come from virtually any source, i.e.: self, a drug dependency program, family, friends, medical personnel, social service agencies, the legal system, etc.


The person making the referral must be able to provide basic information necessary for admission. Persons under the age of sixteen (16) generally require the consent of their parent or guardian. In some cases, the person may be deemed an ‘emancipated adolescent’, and parental/ guardian consent is not necessary. This status may only be determined in consultation with the director.



Admission Criteria


a)         That the adolescent is in a state of substance intoxication, or withdrawal.


b)         That there is an inability to control the substance use.


c)         That the individual requires regular use to function.


d)         That the home situation is such that the adolescent may not be able to resist pressures to use, and thus needs a period during which they may examine their life and that which is important to them, in a supportive environment.


e)         The individual must accept voluntary admission and be compliant regarding the     rules and procedures of the Unit.





















The Treatment Orientation Program is designed to instill within the adolescent a greater understanding of self, coupled with an awareness of drugs and their effects.


The program is of two (2) days duration. The group size may number from 8 to 20 on a day patient basis, and normally is held on a weekend.





All adolescents attending the weekly group meetings are eligible as well as others, who, in the opinion of staff, might benefit from the experience. Normally, young people may attend the program once. However, in special cases with the approval of the coordinator, the program may be repeated.


All Youth Supporters who aspire to be members of the core group and go on to Youth Support training must complete the Treatment Orientation Program.


If the program is an overnight experience, rules and regulations apply as with recreational activities. (See section -Recreation)



























(This program uses as its basis the ‘Self Assessment Guide for Youth’. Zarek & Sipe, Johnson Institute, Minnesota, 1987)










 8:30 am   -  9:00 am                 Introduction and warm-up


 9:00 am   - 10:00 am                Section 1 - Chemicals and Feelings*


10:00 am -  10:15 am                Break


10:15 am -  11:00 am                Discussion


11:00 am -  11:30 am                Video: Choices and Consequences* Part 1


11:30 am -  12:00 am                Section 2 - Chemicals and Behaviour


12:00 pm -  1:00 pm                  Lunch and Recreation


1:00 pm -  1:30 pm                    Discussion


1:30 pm -  2:15 pm                    Sections 3 & 4: Chemicals, School and Work

                                                                        and Chemicals and Friends


2:15 pm -  2:45 pm                    Discussion


2:45 pm -  3:00 pm                    Break


3:00 pm - 3:45 pm                     Section 5: Chemicals and Family


3:45 pm - 4:15 pm                     Discussion


4:15 pm - 4:30 pm                     Wrap-up and introduce the evening program


6:00 pm - 6:45 pm                     Video: Different Like Me


6:45 pm - 8:00 pm                     Introduce role-play Family Sculpture
















   8:30 am - 9:00 am                  Warm-up and Recap


   9:00 am - 9:45 am                  Sections 6 & 7: Chemicals and Self - Concept

                                                                   and Chemicals and Growing Up


  9:45 am - 10:15am                  Discussion


10:15 am - 10:30am                  Break


10:30 am - 11:00am                  Choices and Consequences: Part 2


11:00 am - 11:30am                  Discussion regarding Choices and Consequences


11:30 am - 12:45pm                  Lunch and movie


12:45 pm - 1:15 pm                   Recreation Break


 1:15 pm - 2:00 pm                    Sections 12 & 13: Patterns of Chemical Use

                                                                        and Chemical Abuse and Dependence


 2:00 pm - 2:15 pm                    Break


 2:15 pm - 2:45 pm                    Discussion


 2:45 pm - 3:30 pm                    Section 14: Developing an Action Plan

                                                (Group completes this section with Facilitator)


 3:30 pm - 4:00 pm                    Closure                       









            (See documentation)


*Videos available from:                                                                                        

Sunburst Technology                                                                                                                    101 Castleton Street, Pleasantville, NY 10570 USA                                                                Phone: 1-800-431-1934 International Info: (Outside the USA) Call 1-914-747-3310                   Fax: 1-914-747-4109 Web:












All participants are selected from the existing caseload of the clinician. Eligibility for training as a Youth Supporter reflects the following criteria:


1)         a) Two months of substance-free lifestyle, namely that the individual refrains from the use of alcohol, non-prescribed drugs and illicit chemical substances.


            b) Expressed attitudinal change and demonstrated behavioural change by the         individual, within a substance dependent family.


2)         To demonstrate the positive qualities that are necessary for a helping relationship, or the potential to develop these qualities, such as:


            - a commitment to personal growth;

            - a willingness to listen to others;

            - a sense of caring, openness and compassion;

            - a respect for self and others;

            - organizational, planning, leadership and decision-making skills.


3)         To possess the willingness and the ability to make a six month commitment to the training, implementation and follow-up of the Youth Support relationship. This may be addressed in a treatment contract between the individual and their children.


4)         To be able to function in group settings. This is critical to the training and    implementation process, as well as the ongoing feedback for the support relationship, the supervision of the Youth Supporter and the optional involvement in public presentations.


5)         Expected school performance must be acceptable to the individual, parents or        guardians, and the school. These appropriate levels of expectations should include       marks, attendance and attitude.


6)         To express a willingness to participate in initial and ongoing training sessions. These include T.O.P. (or equivalent) and additional sessions that focus on developing an understanding of the physiological, psychological, social and spiritual aspects of drug use.


















The first phase of the training consists of several sessions focusing primarily on empathic listening skills. These sessions employ a combination of didactic and experiential methods. the mode of delivery of training may be day-long workshops where several topics are covered, or sessions spread over several weeks, depending on the style and choice of the clinician. (Any further reference in this document to presentation/communication focuses on counseling, rather than public speaking.)


The second phase of the training consists of a practicum and a series of follow-up activities. These follow-up sessions are determined by the expressed needs of the Youth Supporters, but will focus primarily on developing skills in feedback, confrontation and problem-solving, as well as coping with feelings and termination. Outside resource persons may be used in the delivery of the training program. Public speaking skills are only included if the clinician perceives a therapeutic benefit for the client.



Aims and Objectives


The overall purpose of the training program is to develop appropriate listening skills and to highlight acceptable intervention strategies in conjunction with realistic limitations presented by the Youth Support relationship and the capabilities of the individual.


The training objectives may be stated as follows: