<p> CP&P 11-45 (new 8/2006) State of New Jersey DEPARTMENT OF HUMAN SERVICES Division of Child Protection and Permanency Adolescent Substance Abuse Assessment Referral Form</p><p>PART I (Completed by Worker) Identifying Information Date referred: ______Name of agency: Address: ______Current case status (check all that apply): CPS Investigation CWS Assessment Permanency Transfer Name of adolescent allegedly using or abusing substances: ______Sex: Male Female Birth date: ______Case ID/KC #: ______Person ID/Member #: ______Name of Local Office: ______Address: ______Worker: ______Telephone/Ext.: ______Supervisor: ______Telephone/Ext.: ______Name of health insurance, including Medicaid: ______ID #: ______Address where adolescent is living: ______Placement? Yes No If placed, what was the date of initial placement? ______Mother: ______Telephone: ______Address (if different from adolescent): ______Father (if known): ______Telephone: ______Address (if different from adolescent): ______Name of caregiver(s) or legal guardian(s) (if adolescent not living with parents): ______Address: ______Telephone/Ext.: ______Temporary Assistance for Needy Families/General Assistance eligible? Yes No TANF/GA #: ______Siblings' names/ages: (Check) In-Home: Out-of-Home: Date of initial placement: 1.______2.______3.______4.______Education Name of school currently attending: ______Grade level: ______Address: ______School contact:______Telephone/Ext.:______Adolescent classified? Yes No Classification: ______Individualized Education Program? Yes No Medical Does the adolescent have any history of violent crimes or psychiatric hospitalization? Yes No DSMIV Diagnosis Axis I: ______Is the adolescent taking any medications? Yes No If yes, list type, dosage, and frequency: ______CP&P 11-45 (new 8/2006) ______Court Involved Is the adolescent court-involved? Yes No Is the treatment court ordered? Yes No If yes, what are the charges/offenses? ______Name of adolescent's Probation Officer: ______Telephone/Ext: ______PART II (Completed By Worker and Supervisor) Reason for Referral Type(s) of substance(s) reported/alleged and duration of use (select substance(s) from National Institute on Drug Abuse, </p><p>NIDA, chart which is attached): ______Level of cooperation with treatment by adolescent: Poor Fair Good Has the parent/caregiver/guardian agreed to participate in treatment? Yes No Availability for appointments: Adolescent: Days: ______Evenings: ______Parent: Days: ______Evenings: ______Caregiver/Guardian: Days: ______Evenings:______Summary of why adolescent needs substance abuse treatment (relevant to alleged substance use or abuse): ______</p><p>Previous substance abuse treatment history (include agency name and address): ______Please provide psychiatric/psychological assessment if completed in the last twelve months. Check, if reports attached. Identify: ______</p><p>(For transfer cases with no new Worker, Parts I and II are completed by the previous Supervisor.) PART III (Completed By Gatekeeper/Liaison) Telephone or in-person conference held with Worker and/or Supervisor regarding the referral? Yes No Results of Conference: ______PART IV SIGNATURES: CP&P Worker: ______Date: ______CP&P Supervisor: ______Date: ______For transfer cases: Signature of CP&P assigned Supervisor or Casework Supervisor: ______Date: ______CP&P Casework Supervisor: ______Date: ______CP&P Gatekeeper/Liaison: ______Date: ______Treatment Provider Counselor: ______Date Received: ______Appointment Date and Time:______</p><p>2 CP&P 11-45 (new 8/2006)</p><p>COMMONLY ABUSED DRUGS Visit NIDA at www.drugabuse.gov Substance: Category and Name Examples of Commercial and Street Names Cannabinoids hashish boom, chronic, gangster, hash, hash oil, hemp marijuana blunt, dope, ganja, grass, herb, joints, Mary Jane, pot, reefer, sinsemilla, skunk, weed</p><p>Depressants Amytal, Nembutal, Seconal, Phenobarbital: barbs, reds, red birds, phennies, tooies, yellows, yellow jackets barbiturates benodiazepines (other than flunitrazepam) Ativan, Halcion, Librium, Valium, Xanax: candy, downers, sleeping pills, tranks fluitrazepam *** Rohypnol: forget-me pill, Mexican Valium, R2, Roche, roofies, roofinol, rope, rophies GHB *** gamma-hydroxybutyrate: G, Georgia home boy, grievous bodily harm, liquid ecstasy methaqualone Quaalude, Sopor, Parest: ludes, mandrex, quad, quay *** Associated with sexual assaults</p><p>Dissociative Anesthetics ketamine Ketalar SV: cat Valiums, K, Special K, vitamin K PCP and analogs phencyclidine: angel dust, boat, hog, love boat, peace pill</p><p>Hallucinogens LSD lysergic acid diethylamide: acid, blotter, boomers, cubes, microdot, yellow sunshines mescaline buttons, cactus, mesc, peyote psilocybin magic mushroom, purple passion, shrooms</p><p>Opioids and Morphine Derivatives Empirin with Codeine, Fiorinal with Codeine, Robitussin A-C, Tylenol with Codeine: Captain Cody, Cody, schoolboy: (with glutethimide) doors & fours, loads, pancakes and syrup codeine fentanyl and fentanyl Actiq, Duragesic, Sublimaze: Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder analogs 8, TNT, Tango and Cash heroin diacetylmorphine: brown sugar, dope, H, horse, junk, skag, skunk, smack, white horse morphine Roxanol, Duramorph: M, Miss Emma, monkey, white stuff opium laudanum, paregoric: big O, black stuff, block, gum, hop oxycodone HCL OxyContin: Oxy, O.C., killer hydrocodone bitartrate, acetaminophen Vicodin: vike, Watson-387</p><p>Stimulants Biphetamine, Dexedrine: bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers amphetamine Cocaine hydrochloride: blow, bump, c, candy, Charlie, coke, crack flake, rock, snow, toot cocaine</p><p>MDMA (methyl- enedioxymethamph- etamine) Adam, clarity, ecstasy, Eve, lover’s speed, peace, STP, X, XTC methamphetamine Desoxyn: chalk, crank, crystal, fire, glass, go fast, ice, meth, speed methylphenidate (safe and effective for 3 CP&P 11-45 (new 8/2006) treatment of ADHD) Ritalin: JIF, MPH, R-ball, Skippy, the smart drug, vitamin Ra nicotine cigarettes, cigars, smokeless tobacco, snuff, spit tobacco, bidis, chew</p><p>Other Compounds anabolic steroids Anadrol, Oxandrin, Durabolin, Depo-Testosterone, Equipoise: roids, juice inhalants Solvents (paint thinners, gasoline, glues), gases (butane, propane, aerosol propellants, nitrous oxide), nitrites (isoamyl, isobutyl, cyclohexl): laughing gas, poppers, snappers, whippets</p><p>Alcohol booze, bottle, brewsky, brew, coolers, forty, forty ouncer, hooch, juice, Kool aid, happy juice, pounder, sauce, shooter, shots, sixer, suds, tea, tonic, White Lightening, vino, cold one, moonshine, Wahoo Juice; Beer bongs and shotguns are used to get intoxicated quickly</p><p>4</p>