DEBA-JEU 10juin2009 (37599 - Draft, VersiForm)
DEBA-JEU_10juin2009 (37599 - Draft, VersiForm) Author: recherche01 Created Date: 6/29/2009 3:49:05 PM
4041231094 DÉBA - Jeu-8 Détection et besoin daide en regard
DÉBA-Jeu-8_2017-02-27 17 Voulez-vous recevoir de l'aide pour changer vos habitudes de jeu? Oui Non 13 Depuis un an, êtes-vous retourné jouer pour vous refaire (regagner l'argent perdu auparavant)? 12 Depuis un an, avez-vous connu des périodes où vous avez longuement pensé au jeu, soit en
DÉBA-JEU-8 ENG 2016-03-08 (39223 - Ebauche, VersiForm)
DÉBA-Jeu-8_ENG_2016-03-08 17 Would you like help with your gambling? Yes No 13 In the last year, have you ever went and gambled to win back money that you had previously lost? 12 In the last year, have there been times where you have spent a long time thinking about
MANUEL DUTILISATION du DÉBA-Alcool/Drogues/Jeu
Auteurs du DÉBA-Jeu Joël Tremblay, Ph D , UQTR Jean-Marc Ménard, M Psy , Domrémy Mauricie / Centre-du-Québec Francine Ferland, Ph D , Centre québécois d’excellence pour la prévention et le traitement du jeu (CQEPTJ) Semblable à la version adaptée pour le Programme de formation en dépendances pour les CSSS Révisé, mars 2012
MANUEL DUTILISATION du DÉBA-Alcool/Drogues/Jeu-8
Jeu-8 : Détection et besoin d'aide en regard du jeu excessif, Québec, Service de recherche en Dépendance du CIUSSS de la Capitale-Nationale et du CISSS de Chaudière-Appalaches, www risqtoxico ca
LES CRITÈRES MODÈLES THÉORIQUES
Deba-Jeu Critères DSM J APPROCHE TCC C C excitation associée au jeu C O Programmes intermittents Difficultés à contrôler l ’activation émotionnelle et à mettre en question les pensées irrationnelles Résolution de problèmes; impulsivité et restriction dans les stratégies de « faire face »
SERVICE REQUEST – YOUTH AND ADULT REFERRAL TO THE CRD
User record CLI-60367A (Rev 2021-01) Page 1 of 2 Facility: _____ SERVICE REQUEST – YOUTH A TO ND DULT REFERRAL THE CRD PATIENT IDENTIFICATION
Efficacy of a randomized controlled trial of Integrative
Efficacy of a randomized controlled trial of Integrative Couple Treatment for Pathological Gambling/ ICT-PG: 18 month follow-up Joël Tremblay, Ph D , Psychoeducation Department, Université du Québec à Trois-Rivières (UQTR)
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User record CLI-60367 ;Ğǀ͘ϮϬϮϭͲϬϭͿ
Page 1 of 2
Facility: _______________________________________________ SERVICE REQUEST - YOUTH AND ADULT REFERRAL TOTHE CRD
PATIENT IDENTIFICATION
Address:
City: Postal code:
Email:
Phone no. - home:
Phone no. - work:
ADDITIONAL INFORMATION ABOUT THE USER
Father's name :
(Last name) (First name)Native language: Place of birth: Québec
- Other Specify:OCCUPATION (adult section)
- Looking for a job - Full-time studies/training - Part-time studies/training - Full-time work (35+ h/week) - Part-time work (< 35 h/week) - Volunteering - Sick leave, parental leave, strike - Detained - Homeless - Seasonal worker on leave - Disability/Inability to work - Retired - Homemaker - Other:LIVING SITUATION
- Living with one or several relatives - Living with one or several non-related persons (foster home, youth centre, etc.) Single-parent Couple with child(ren) under 18 - Couple without children - Person living aloneSERVICE REQUEST - YOUTH AND ADULT
REFERRAL TO THE CRD
SERVICE REQUEST: PREFERRED LANGUAGE:
YOUTH* (age 17 and under) ADULT FRENCH ENGLISH
REFERRAL BY THE DIRECTOR OF YOUTH PROTECTION (DYP), including the YOUTH CENTRESYouth campus
OE UNIT (where applicable):
Address:
IDENTIFICATION OF REFERRING PERSON
Last name: First name:
Organization: Phone:
Other professionals involved:
(Last name) (First name) COMMENT:User record CLI-60367 ;Ğǀ͘ϮϬϮϭͲϬϭͿPage 2 ŽĨ 2 SERVICE REQUEST - YOUT
H AND ADULT REFERRAL
TOTHE CRD
CIVIL STATUS
Single Common-law Divorced Married
Separated Widow(er) Other:
from the CRD of the CISSSMO (Virage or Foster) - NoEmergency contact:
(Last name) (First name)Email: Relationship with user:
Phone no.: Cell no.:
REFERRED USER'S PROBLEM
- Alcohol - Drugs - Medications - Gambling - Cyber-dependence - EntourageSCREENING TOOLS (attach to form)
- DEP-ADO - DÉBA Alcool - DÉBA Drogue - DÉBA JeuScore Score Score Score
USER'S AVAILABILITY
- Morning - Afternoon - EveningCOMMENT:
AUTHORIZATION TO EXCHANGE INFORMATION
I authorize to send this referral form, the completed screening tools, and allinformation related to the referral to the CISSS de la Montérégie-Ouest's Centre de réadaptation en dépendance (CRD).
I authorize the referring healthcare professional to exchange information about this referral with the healthcare professional at
the CISSS de la Montérégie-Ouest's Centre de réadaptation en dépendance (CRD).THIS AUTHORIZATION IS VALID FOR 90 DAYS
I understand that I may change or cancel this authorization at any time. Signature of user or legal representative yyyy-mm-dd Signature of referring healthcare professional yyyy-mm-dd PLEASE SEND THE SIGNED FORM AND A COPY OF THE COMPLETED SCREENING TOOL TO THE CENTRALIZED INTAKE DEPARTMENT OF THE CISSS DE LA MONTÉRÉGIE-OUEST'S CRD Montérégie (French - English) Montréal (English)Fax: 450-443-0522 Fax: 514-486-2831
Email: accueil.dependances.cisssmo16@ssss.gouv.qc.ca Email: accueil.montreal.dependance.cisssmo16@ssss.gouv.qc.ca