Referral | NAFFA Wellness

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NAFFA Wellness puts the security of the client at a high priority. Therefore, we have put efforts into ensuring that the information you send is safe and only seen by authorized staff, if you have any questions, please do not hesitate to reach out to NAFFA Wellness staff.

NAFFA WELLNESS REGISTRATION

Referring Agency Information

Date

Email

Agency & Name/Title

Fax

Phone Number

Address

Client Demographics

Name

Date of Birth

Phone Number

How did you hear of NAFFA Wellness?

Preferred Contact

Alt. Phone Number

Tribal Affiliation

Access to internet or phone to participate in telehealth or groups?

Disabilities

Highest Level of Education

Court Ordered

Emergency Contact

Name/ Relation

Phone Number

Legal

Court invovled?

Sex Offener?

DCS/TSS Involved?

Probation Involved?

Currently Incarcerated?

Legal Invovlement Details

Probation / Parole Officer / Case Worker / Court Contact

Name

Phone

Fax?

Address

Presenting Problem:

Symptoms

Depression

Self- Harm

Hallucinations

Physical Aggression

Low Self-Esteem

Impulsivity

Hyper - Active

Sleep Disturbances

Change in Eating Habits

Poor Interactions with Family, Friends and/or Peers

Other

Not Applicable

Safety Elements

Suicide Attempt * Required

Current

Over a year ago

Not applicable

Suicidal Ideations * Required

Current

Over a year ago

Not applicable

Physical Aggressions * Required

Current

Over a year ago

Not applicable

Sexual Perpetration * Required

Current

Over a year ago

Not applicable

Self - Harm * Required

Current

Over a year ago

Not applicable

Other * Required

Current

Over a year ago

Not applicable

Describe history and identify safety risks

Alcohol

Age of first use

How often is drug taken?

When was last use?

Marijuana

Age of first use

How often is drug taken?

When was last use?

Spice (K2 synthetic THC)

Age of first use

How often is drug taken?

When was last use?

Cocaine

Age of first use

How often is drug taken?

When was last use?

Heroin

Age of first use

How often is drug taken?

When was last use?

Prescription Opiates

Age of first use

How often is drug taken?

When was last use?

Fentanyl

Age of first use

How often is drug taken?

When was last use?

Methamphetamine

Age of first use

How often is drug taken?

When was last use?

Dextromethorphan (Triple C’s)

Age of first use

How often is drug taken?

When was last use?

Hallucinogens

Age of first use

How often is drug taken?

When was last use?

Anabolic Steroids / PEDs

Age of first use

How often is drug taken?

When was last use?

Other

Age of first use

How often is drug taken?

When was last use?

Describe history and identify substances

Additional items requested: Tribal ID, CIB, or Letter of Tribal Affiliation (if available)

Thanks for submitting!

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info@NAFFAWellness.com

(480)536-8881

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