Untitled Document

Antidote TOP Form Submission

First Name (or Client Reference if known):
Surname (or Client Initials if Client Ref is known):
TOP Date (dd/mm/yy):
Treatment Stage:
Attendance:
Session Type:
Location:
HIV Advice & Information given?:

Section 1: Substance use (Please use NA only if information is not disclosed or not answered.)
	Week 4	Week 3	Week 2	Week 1
Alcohol Average (units/day):
Opiates Average (g/day):
Crack Average (g/day):
Cocaine Average (g/day):
Amphetamines Average (g/day):
Cannabis Average (spliff/day):
Other Problem Substance Average (g/day):
Other Problem Substance Name:
Section 2: Injecting risk behaviour (Please use NA only if information is not disclosed or not answered.)
	Week 4	Week 3	Week 2	Week 1
Injected
Inject with needle or syringe used by someone else?
Inject using a spoon, water or filter used by someone else?
Section 3: Crime (Please use NA only if information is not disclosed or not answered.)
	Week 4	Week 3	Week 2	Week 1
Shoplifting
Drug Selling
Theft Vehicle:
Other Property Theft:
Fraud etc:
Committing assault or violence:
Section 4: Health and social functioning (Please use NA only if information is not disclosed or not answered.)
Psychological Health Status:
	Week 4	Week 3	Week 2	Week 1
Paid Work
Attended College or School
Physical Health Status:
Acute Housing Problem:
At Risk of Eviction:
Quality of Life:

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