Mental Health and Addictions Palmerston North Online Referral Your Details Current Status How We Can Help Finishing Up Order Number Section 1: Your Details Let us get to know you a little. Tell us some basic details about you Legal First Name * Legal Last Name * Preferred Name Date Of Birth * Gender * NHI Number (if Known) Ethnicity * Iwi Now let us know how to best get back to you. Street Address * City * Post Code (If Known) Primary Contact Number * Secondary Number Email Address How do you prefer to be contacted? * Phone Email TXT message Section 2: Your Current Status Let's find out a little more about you and what your current status is Do you have any children in your care? * Yes No Is there anyOranga Tamariki (CYFS) involvment? * Yes No Are you on EM Bail? * Yes No Are you engaged with any other MH/Addiction services? * Yes No Are you engaged with Community Corrections/Probation? * Yes No Do you have any pending charges with the courts? * Yes No Do you have any medical or mental health concerns? * Yes No Any additional support required? * Yes No What other services are you engaged with if any? Do you have any protection/non association orders or conflicts of interest? Section 3: How we can help you Nearly done! We just need some details on how we can best help you achieve your goals What substance/s are you (or have been) using? Substances Used Alcohol Benzodiazepines Cannabis IV Drug Use LSD/Hallucinogens Other Drug/Substance Substances Used Meth/amphetamines Opiates Solvents Synthetic Highs Prescription Medication What are the top three concerns? Concern #2 Concern #3 Services we Provide Community Day Programme The eight-week Monarch Programme is an educational and life skills based programme that addresses addiction, mental health and social issues. The community option is recommended for people who have healthy support in the community or are unable to leave their home. Attendance of the programme is Monday to Friday 8.30am – 12.30pm Residential Programme The eight-week Monarch Programme is an educational and life skills based programme that addresses addiction, mental health and social issues. The residential option is recommended for people who are more vulnerable, from out of town, at risk in their environment, unable to maintain abstinence without 24 hour support, are in abusive relationships, or influenced by peer pressure. This is a supported living environment through 24/7 support and supervision. Attendance of the programme is Monday to Friday 8.30am – 3pm. Community 1:1 Support Individual and confidential counselling to address your substance use needs. WRAPPED WRAPPED is an interactive psycho social-educational programme, designed to help you in your individual recovery journey. You will complete a self-assessment that will help you identify triggers and stressors, helping you to learn and develop tools to manage cravings and reduce substance use. This programme runs on Mondays and Thursdays 1:00PM – 2:30PM for six weeks. You can attend as little or as much as you like. Support Groups Support group is a safe non-judgemental group where you can just “be”. What service/s would you like to attend * Community 1-1 Support Monarch Residential Programme Support Groups WRAPPED Monarch Community Day Programme I'm Not Sure See "Services We Provide" Above for a detailed description of each of the listed services Section 4: Finishing up! We think we've got everything we need, but if we've missed something, please do let us know. When you're satisfied there's nothing else to add, hit the submit button to get things underway Anything else you'd like to add?