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Doc 1300 Telmexw Awtexw Medicine House Treatment Centre (Telmexw) Application Package Overview (25 pages) 1. Eligibility Guidelines (keep for your reference)………………………………………………....2, 3, & 4 2. Client Program Guidelines (keep for your reference)………………………………………….5, 6, & 7 3. Client Check List (keep for your reference)…………………………………………………...………...8 4. Application for Admission Form…………………………………………………………………………..9 5. Treatment and Counselling History……………………………………………………………….10 & 11 6. Social Support System…………………………………………………………………………………...12 7. Medication Administration and Medical Needs………………………………………………………..13 8. Pre-Admission Medical Status Form……………………………………………………………………14 9. Prescription Form…………………………………………………………………………………………15 10. Income Assistance Funding Form……………………………………………………………………..16 11. Legal History Form………………………………………………………………………………………17 12. Voluntary Consent for Release of Information Form………………………………………………...18 13. Alcohol Screening Test & Drug Screening Test……………………………………………………...19 14. Alcohol & Drug History………………………………………………………………………………….20 15. Contract for Methadone Maintenance Program……………………………………………………...21 16. Consent to attend and participate in Treatment……………………………………………………...22 17. Travel Form………………………………………………………………………………………………23 18. Driving Directions (keep for your reference)………………………………………………………….24 Sent in a separate attachment if received by e-mail 19. Letter to Meth Dr. 20. Letter to Medical Practitioner Once you have completed the necessary forms, submit them by fax or mail for screening. Have your Medical Practitioner complete the medical forms, then forwarded to us. Submit written confirmation of a negative TB test result (x ray or skin test within the last

twelve months). If you have any questions or need assistance at any time, please contact our Intake Coordinator or our Program Manager.

Sts’ailes Snowoyelh | www.stsailes.com

Doc 1305 – page 1 of 3 (keep for your reference) Eligibility Guidelines Telmexw Awtexw Medicine House (Telmexw) Client must have 7 days abstinence from drugs and alcohol prior to admission and must not require medical Detox. NO EXCEPTIONS!! For Methadone Harm Reduction info see page 4.

1. Client self identifies as Aboriginal, Métis or Inuit and 19 years of age or older.

2. Client must be referred by an A&D counselor Referral Worker who is willing to participate in aftercare planning as requested for their referred client.

3. Complete application should include the following: Pre-admission Medical, TB results, and any

supporting documentation such as probation orders, hospital reports, etc, must be submitted prior to acceptance in our program.

4. Telmexw is not under any obligation to accept Aboriginal Delegated Agencies (ADA) or MCFD

mandated or court ordered clients.

5. Client is free from outside interference during the treatment program such as court appearances, ADA or MCFD Case Conferences, medical and/or other appointments.

6. The client must not have any upcoming legal issues/court cases. ALL court dates must be dealt

with prior to admission to Telmexw

7. Telmexw does not accept client’s with the following legal conditions: a) Electronic Monitoring, b) Temporary Absence, c) 24 Hour Supervision, d) Day Parole, e) all other legal conditions are reviewed on a case by case basis.

8. Telmexw does not accept known, charged, or convicted sexual offenders, however, we may

review on a case by case basis for sexual offenders who have completed sexual offender treatment and have been assessed at minimum risk to re-offend.

9. Clients with criminal convictions and or charges that may put the community at risk must be

screened on a case by case basis.

10. Please Note: We are unable to accommodate wheel chair access needs.

http://www.stsailes.com/


Doc 1305 – page 2 of 3 (keep for your reference) Medical Admissions

1. Client must not require medical Detox or acute care; we request all persons in active addiction complete standard seven day medical Detox at a Detox centre.

2. Clients with a Dual Diagnosis must, with their referring worker, provide all relevant

documentation-verifying their mental stability.

3. Status First Nation’s clients are required to have a current status card to verify their status number for prescription coverage as needed or required by Agassiz Pharmasave.

4. Telmexw is not responsible for any additional expenses not covered by the client’s current

medical coverage. (Telmexw medical exam and TB testing are admissible for 12 months from date they were administered.) Intake Process

1. Please ensure application is complete before sending as this will help to speed up the intake and screening process.

2. Single sided applications may be faxed as Confidential ATTN: Program Manager f 604 796

9839.

3. Once the application is received and reviewed and the client meets the admission criteria, the Program Manager or Intake coordinator will contact the referral worker by phone and letter to confirm client’s admission and intake date. Confirmation letters are sent out by fax wherever possible to allow sufficient time to coordinate travel arrangements.

4. Travel moneys are usually supplied by the subsidy-funding source; travel arrangements are to be

coordinated with the referral worker. First Nations and Inuit Health will not pay return travel costs for clients who do not complete treatment. The client must be prepared to absorb the return travel costs if they leave treatment incomplete or are not accepted due to insufficient clean/sober time.

After Care - Progress and Follow Up

1. Telephone case conference calls and/or video conferencing are conducted with the referral worker to review client's progress.

2. After Care planning commences at the onset of treatment. 3. A written Aftercare plan is jointly prepared with your referring counsellor at discharge. A

discharge conference call is made between the client, primary treatment counselor, and Aftercare counselors.

4. The clients Final Report is mailed to the designated person(s) identified on the Consent to

Release of Confidential Information. A client may change the name of the person(s) on the consent at any time and it is up to the client to inform their referral worker of the change.



Doc 1305 – page 3 of 3 (keep for your reference) METHADONE HARM REDUCTION TREATMENT We accept clients on the Harm Reduction Methadone Maintenance Program. We do not accept clients on methadone for pain management. Client’s on Physician Monitored Harm Reduction Methadone Maintenance Management

1. The client must have: a Physician Order stating client is stabilized on methadone and indicating Telmexw designated staff can dispense the witnessed daily dose a Physician Order listing all medications client is prescribed please ensure all prescriptions cover a one week supply and a minimum of a 4 day carry for methadone.

2. Methadone will be supplied by the pharmacy from date of admission until discharge.

3. Following confirmation of the client coming to Telmexw, you must make sure that the client’s

personal and/or methadone-dispensing physician makes contact with our Program Manager or our Intake Coordinator and/or our Nurse Practitioner to discuss the client’s methadone coverage while in treatment. Our Nurse Practitioner will assist in coordination of methadone services with Dr. Fox, a local methadone prescribing physician.

4. Upon admission the client must sign a contract for treatment along with other important forms.

5. It is imperative that the client be aware of the mandatory random supervised urine samples that

may be requested for drug screening upon admission and throughout treatment as deemed necessary.

6. It is also imperative that the client be aware that Methadone is administered and witnessed daily

by Telmexw designated staff and/or licensed methadone prescriber in the Medical office. Client’s methadone dosage will not be altered while in treatment without the Nurse Practitioner and/or Prescribing Physician approval.

7. The referring counsellor must submit a completed Telmexw referral package to the Centre

(attention to the Program Manager). The Pre-admission Medical Evaluation must also be completed and sent to the Centre with the application.

8. Prior to admission all clients must have evidence that they are free of TB. (A Mantoux test can be

done at any Public Health Unit). Please arrange this as soon as you refer the client. (If the Mantoux test is positive a Chest X-ray must be arranged – results of the X-ray may take 6 weeks).

If you have any questions or need assistance at any time, please do not hesitate to contact our Intake Coordinator or our Program Manager.



Doc 1310 – page 1 of 5 (keep for your reference) Client Program Guidelines Telmexw Awtexw Medicine House Treatment Centre (Telmexw) Program Guidelines reflect respect, consideration, cooperation and self-responsibility. Telmexw believes these are four essential components of your personal recovery and self-empowerment. Our guidelines will help to ensure your physical, mental, emotional and spiritual safety are being met and allowing you to participate fully in the program. Please read the guidelines carefully and be prepared to follow them. Alcohol and Drugs

• The possession or use of alcohol or non-prescribed drugs by clients while in treatment is not acceptable and will result in immediate dismissal from treatment.

• A personal baggage check is conducted upon entry and return from weekend and or day passes. Admission Intake

• Upon arrival and under supervision, staff will conduct a search of your belongings for any: a) Contraband articles (e.g. knives, shavers, razors, nail clippers, drugs, radios, computer or

electronic devices, meal replacements etc.) b) Paraphernalia Clothing and Pornographic material (e.g. logo T-shirts portraying, alcohol,

drugs, violence, racism etc, bandanas gang affiliated garb etc.) c) After shave lotion, hairspray, nail polish and remover, mouthwash etc. (anything

containing alcohol) must be turned in to Staff on duty for safekeeping. d) Personal cell phones will be turned into Staff for safekeeping throughout the program and

signed in and out only when you are leaving for a pass. • Vehicles: If you bring your vehicle to treatment, you will have to turn in your keys to safe keep. • Do not bring electronic devices such as walkman, Discman, IPod, mp3’s, TV, CD’s or cassettes

or recorders, movies etc. If you do bring them they will be put in safe keeping during your stay. We have very limited storage space, so we strongly encourage you to leave your electronics at home or with family or friends while you are in treatment.

Telephone Calls

• Upon your arrival you can make one phone call to confirm your safe arrival. • There are absolutely no telephone calls allowed during the first two weeks of treatment. This

allows you the opportunity to focus on yourself and your treatment program. • After two weeks of treatment local phone calls can be made from the client’s phone on Fridays

and Saturdays between 6pm to 10pm. • Ensure you log all your calls in the resident telephone call logbook. You will need a phone card

for long distance calls. • In respect of others, calls will be limited to fifteen minutes. • No personal calls permitted during outings, i.e. AA meetings or other off site group activities. You

will not be called from session for personal calls. Messages if you have any will be given to you during breaks.



Doc 1310 – page 2 of 5 (keep for your reference)

• If an incoming phone call is indicated as an emergency, we will inform you immediately and support you to deal with this emergency appropriately.

• Using the telephone without approval or at undesignated times will result in a warning and may be grounds for your discharge.

Incoming Mail or outgoing mail

• If you have any mail in it will be delivered to your mailbox during your break times. • If you have any outgoing mail, please give to one of the program support workers. • Telmexw will restrict any incoming mail, calls from past clients or any person attempting to

interfere with your treatment. All communications received, if any, will be given to you once you leave treatment.

Day Passes and Overnight Passes Passes are a privilege, not a right – they are earned. Approval of individual/personal outings is dependent on your demonstrated progress in the treatment program:

• After completion of a 28 day block you may request a day pass. Day passes are on Saturdays only, from 10am to 6pm.

• After every completion of a 28 day block you may request an overnight pass. Overnight passes are from 10am Saturday to 6pm Sunday.

• Submit your pass requests on Wednesdays. • Your pass requests will be reviewed and may or may not be approved. • Resident chores must be completed prior to leaving on a Pass and responsible arrangements are

to be made for your chores while you are on Pass. • Responsible arrangements are to be made for your own transportation. • Upon your return from a Day Pass or Weekend Pass, your bags etc will be checked for

contraband items. • Use the “Sign In and Out” log whenever you leave the centre.

Note: *Always inform staff -when you are leaving -when you are back -if you have canceled your day pass or overnight pass -or if you will be late because of an emergency while you are on a pass. *If at any time you feel you need to return from a day/overnight pass you are welcome to do so. Please call us to ensure someone will be at the facility. Health & Safety

• Smoking is allowed outside in the designated smoking areas. No smoking inside or on the balconies anywhere!

• You must keep your door unlocked in case of fire. • Inform a staff person if you wish to have your sleeping area smudged. • All medication will be turned in to the Telmexw staff at intake. Medications will be dispensed at

scheduled times by the designated staff and recorded on your individual medical form.



Doc 1310 – page 3 of 5 (keep for your reference)

• A high standard of personal hygiene is required, including daily baths/showers. • Laundry facilities are available; schedule will be posted on the bulletin board. • Use only the bed you are assigned. • Keep your room clean. • Refrain from profanity. • Lounge area is provided as a common area for all clients. • Sleeping areas are private quarters. No other clients or guests are allowed in your room. • Wash your hands before -handling food or dishes -meals -after using the washroom. • Food must be kept in the dining area. Water is allowable. Popcorn is allowed in the big room

during movies. Dress Code

• You are expected to dress appropriately at all times. • Shorts must be Knee Length. • Sleepwear is to be worn within your bedroom only. • Housecoats are required to be worn as appropriate. • You are required to wear a shirt at all times (excluding in the sweat lodge). • Indoor running shoes or slippers to be worn at all times. No bare feet. • Clothing with Logos promoting alcohol, drugs, racism, sexism, pornographic materials and/or

violence will not be acceptable. • Muscle shirts allowed only for running, sweats and/or gym. • No hats, caps or sunglasses worn during group or mealtimes. • No bandanas or other gang affiliated garments allowed at any time. • Clothing must be modest and non-revealing.

Other

• Money, a maximum of $100 can be held onto in safe keep; Amounts over will not be accepted and should be kept in the bank.

• Valuables must be turned in at admission and after shopping days to be put in safe keep. (Telmexw is not responsible for lost or stolen items).

• Inform staff of your whereabouts (walks, gym, jogging) and remain within the Telmexw boundaries.

• No unsupervised group/circle/spiritual work at any time. • No "counselling" of other clients. • Refrain from lending money, cigarettes or clothing etc. • Clients are not to sell items to each other or to staff. • Clients are not permitted to give gifts to anyone while in treatment.



Doc 1310 – page 4 of 5 (keep for your reference) Proposed Weekday Schedule (Monday - Friday) subject to change

• Wake up 6:30 - 7:30 am • Breakfast 7:30 – 8:00 am • Chores 8:00- 8:30 am • Smudge Ceremony/opening prayers/check in circle 8:30 - 9:30 am • Program sessions from 10:00am 12:00pm • Lunch12:00pm– 12:45pm • Medication 12:00pm • Afternoon sessions 1pm to 3:30pm • Free time and or recreation sessions 3:30pm to 5pm • Supper is served at 5pm • Varied program activities 6pm to 10pm • Medication 10pm • Lights out at 11pm Sunday to Thursday

Weekend Schedule (Saturday - Sunday)

• Wake up / Spiritual bath 6:30 - 7:30 am • Breakfast 7:30 – 8:00 am • Chores 8:00- 8:30 am • Smudge Ceremony/opening prayers/check in circle 8:30 - 9:30 am • Pick up for day pass or overnight pass as approved 10:00am • Planned activities and programming throughout the Day • Lights out at midnight on Friday and Saturday

Client Discharge The objective of this policy is to ensure Telmexw acts with due diligence when clients are discharged prior to completion of treatment.

• A client will be discharged if he has caused injury to another person, vandalized the treatment centre, used alcohol and/or drugs while in treatment, or has become intimately involved with another client.

• Client warnings which may result in discharge will occur when a client has refused to participate in the treatment program, refused to abide by the signed contracts, or has not returned on time from a Pass.

• Clients who have completed treatment or discharged from the program are to have no further contact with other clients still in treatment.



Doc 1310 – page 5 of 5 (keep for your reference) Visitor’s guidelines (please share with your family and other supports) Telmexw is committed to providing the safest possible environment for its client and staff. Guidelines have been established for our client’s protection. We respectfully expect visitors to adhere to these guidelines and boundaries.Please ensure your friends and family members receive a copy of the Visitor guidelines prior to coming to treatment. Ask your referral agent to make copies.

• Clients may request a visit after 2 weeks of stay. • Visiting hours are on Sundays from 1pm to 4 pm. • Visitors must sign in upon arrival and sign out upon departure. • Visitors must sign a Confidentiality form to protect the confidentiality of others in treatment. • Visitors are not permitted in entering any sleeping quarters. Visitors must stay in the common

area. • Visitors who appear to be under the influence of alcohol or drugs will be told to leave. The

assessment of staff will override that of anyone else. • Visitors and clients are required to behave in an appropriate manner, refraining from intimate

behaviors during visitations. • Visits are intended to enhance the Treatment process, therefore, visits that appear to be

disruptive to the client will not be tolerated and the Visitor will be asked to leave. • Any children under 19 years of age visiting at the Centre must be accompanied and supervised

by an adult other than the client at all times. If you have any questions or need assistance at any time, please do not hesitate to contact our Intake Coordinator or our Program Manager.



Doc 1315 – page 1 of 2 (keep for your reference) Client Check List Thank you for applying to attend Telmexw Awtexw Medicine House Treatment Centre (Telmexw). Telmexw is located at16300 Morris Valley Road, Agassiz BC. t 604 796 9829. Please arrive at Telmexw on your scheduled intake day at 11:00am. If you cannot arrive at this time, please let us know well in advance so that we can make alternate arrangements. We ask that you have return transportation arranged prior to your arrival. You must have a return bus or airline ticket or sufficient funds to purchase a ticket. We do not provide coverage for transportation. Please bring the following items:

• Pen, binder, paper and journal • $20.00 Laundry and supply fee (non-refundable) • Personal toiletries (shampoo, soap, toothpaste, etc.) • Appropriate clothing for the season • Running shoes and suitable clothing for recreation (swim suit optional) • Towels & Alarm Clock • A completed Prescription Form (included in Referral Package) for all medications* • Shorts and t-shirt – men, for sweat lodge ceremony

Please do not bring the following items:

• More than 2 pieces of luggage • Items of value (jewellery, etc.) • Any perishable food items • Cameras or video cameras Any electronic devices, personal videos etc. • Large sums of money (a comfort allowance of $20.00/week is recommended) • Clothing that promotes drug paraphernalia, gangs, violence, sex or other inappropriate

representations • Revealing and/or immodest clothing

Please note: Do not bring a vehicle. We do not have secure parking available. Use of a vehicle during your

stay is not permitted and you must turn in your keys to be put in safe keep. Please ensure that you are free from all outside obligations (court dates, appointments, paying

bills, etc.) for the entire program. You will need a phone card for long distance calls. Client phone use is on Fridays and Saturdays

between 6pm to 10pm after 2 weeks of stay. Visiting hours are Sundays 1 to 4pm. You may request a visitor after 2 weeks of stay. Clients must be capable of participating in programming upon admission and must not require a

medically supervised Detox (i.e. alcohol or benzodiazepine withdrawals).



Doc 1315 – page 2 of 2 (keep for your reference) * Telmexw will have the prescription filled upon your arrival. If you have third party coverage for medications, please ensure that you bring the necessary information. All clients are responsible for the cost of their own medications. Please feel free to contact us at any time if you have any questions regarding your scheduled date. We will be happy to assist you in any way we can.



Doc 1300 Application for Admission Form: Referral Date:________________________________

Program applied for: □ Residential Treatment Please fill out this form with your client. Referral Source Information: Referral Source Name: ________________________________________________________________ Position: ________________________________ Agency:____________________________________ Address:____________________________________________________________________________ Phone Number: ( )____________________________ Fax: ( )_____________________________ E-mail: _____________________________________________________________________________ Client Information: Name: _________________________ _______________________ __________________________ First Middle Last

Prefer to be called:_________________________________ □ Male □ Female

Address:____________________________________________________________________________ Apt # Street City Postal Code

Home Phone:_________________________________ Mobile/Alternative: _______________________

Ok to speak to another member of household? □ Yes □ No

Area of Residence:_________________________________ PHN# (Care Card):___________________ Aboriginal Status #______________________________ Band Name:___________________________ Date of Birth: _________________________ Age:___________ SIN: ___________________________ Marital Status:_______________________________ Number of Dependent Children:______________ Education:____________________________________ Employment Status:______________________

□ Smoker □Non-smoker □ Snorer □ Non-snorer

Emergency Contact Person:____________________________________________________________ Relationship:________________________________________________________________________ Contact Number:________________________________ Alternate:____________________________



Treatment & Counselling History:

Name of Previous Programs Attended and dates:

Residential Treatment:

Detox:

Outpatient Counselling:

Day Treatment:

Supportive Recovery/Transition House:

Other:

Prior stay at Telmexw Awtexw? □ Yes □ No If yes, previous admission date(s):

Current Usage Information:

Clean at time of application? □ Yes □ No If yes, clients clean/sober date: Legal:

Do you have any criminal history: □ Yes □ No If you answered yes to the above question, you must complete the Legal History form. Those on probation, parole or with conditional sentences must also send a copy of their conditions with this application. Residential School: Client Attended Indian Residential School Inter-generational Survivor Client Did Not Attend Indian Residential School

Mental Health:

Are you currently seeing a mental health worker, psychologist, or a psychiatrist? □ Yes □ No Worker/Medical Practitioner : Agency:

Phone: ( )

NOTE: Clients must be capable of participating in programming upon admission and must not require a medically supervised Detox (ie. alcohol or benzodiazepine withdrawals).



Currently Being Treated Past Diagnosed/ Treated

Attention Deficit Hyperactivity Disorder

Anxiety Disorder Eating Disorder Obsessive-Compulsive Disorder Post Traumatic Stress Disorder Learning Disability or FAS/FAE Psychosis Borderline Personality Disorder Anti-Social Personality Disorder Depression

Bi Polar Disorder (Manic Depression)

Trauma experiences Chronic Pain Seizures: epileptic or non-specified

In the last year have you attempted suicide? □ Yes □ No

Previous psychiatric hospitalizations? □ Yes □ No If yes, to either question above how long ago?

History of self-mutilation/self-harm? □ Yes □ No If yes, dates:

Hospitalizations in the last year? □ Yes □ No Dates/Reason:

Physical History 1. Does the client have any physical limitations that would prevent them from doing:

Daily living chores, recreational or cultural activities? □ Yes □ No

2. Does the client require a wheel chair accessible room/bathroom? □ Yes □ No STOP HERE if you answered yes, we are unable to accommodate wheel chair access needs.



3. Does the client have any special needs Telmexw awtexw staff needs to be aware of while client is in

treatment? □ Yes □ No 4. If you have answered yes to any of the above questions please explain below

Cultural/Spiritual Aspects

1. Is the experience of First Nation’s culture important for client’s sobriety? □Yes □ No 2. Is the client willing to participate in First Nation’s treatment components such as Sweat Lodge, daily

smudge and other community cultural ceremonies? □ Yes □ No 3. Does the client have specific spiritual/cultural preferences?

** NOTE: We recommend any personal cultural/spiritual items or ceremonial belongings be left at home. If items are brought to the treatment centre they will be placed in safekeeping and terms of access and usage will be assessed in consultation with the clients primary counsellor and as per Telmexw awtexw polices and procedures.

Social Support System

1. Has client attended or is client willing to attend 12 Step help groups ie AA/NA? □ Yes □ No 2. Please list all Aftercare Supports available in the community (ie; 12 step meetings, support groups,

First Nations supports, Elders, family, friends etc.,)

3. Does client have a post-treatment appointment set? □ Yes □ No



MEDICATION ADMINISTRATION AND MEDICAL NEEDS WHILE IN TREATMENT

Telmexw awtexw (Medicine House) Residential Treatment Program is not a medical facility. You must ensure that you are medically stable enough to be in a facility that does not have a Medical Practitioner on site (a visiting Nurse Practitioner and/or Walk-in Clinic is available nearby for basic medical needs). Any medication that you will require during your stay must be bubble-packed in the following manner in order for them to be administered to you:

∗One medication card per medication, per time(s) to be given. For example, if you take Naproxen 250 mg. three times per day, we need one cards of Naproxen 250 mg., to be dispensed one week at a time

Medication administration times occur four times a day- morning, noon, supper and evening. This is a requirement of Community Care Licensing and no exceptions will be made. If you need medication administered outside of these times, the prescription must clearly state this. You can: ∗ Fax a written prescription of your medications (form included in package) and we will forward to

our administrating pharmacy when you arrive (you are responsible for making any arrangements regarding costs)

∗ Methadone Prescriptions: ensure your prescription indicates your daily witnessed doseage is to be dispensed and witnessed by designated Telmexw Awtexw staff and recorded on our MAR sheet as per College and Physicians and Surgeons requirements. We are not able to accept those on Methadone for Pain Management.

MEDICATION AGREEMENT: I understand that Telmexw awtexw (Medicine House) can only administer medications that are prescribed by a Medical Practitioner and bubble-packed in the above-described manner. I agree to pay any cost incurred for my own medications. _________________________________ ____________________________ CLIENT SIGNATURE DATE



Pre-Admission Medical Form To Be Completed By a Medical Practitioner – (Doctor or Nurse Practitioner only)

Patient Information: First Name: Last Name: Health Card #: Date of Birth: Province: Patient Phone #: ______ Height: Weight: BP: Pulse:

Date of last Chest X-ray or Mantoux test for Tuberculosis & results: (A TB test result less than 12 months old is required to qualify for admission, must attach TB test written copy) Drug/Food Allergies:

Medication: Please check all categories representing types of prescription medication that are currently being used:

□ Anti-depressants □ Anti-anxiety □ Anti-psychotic □ Pain medication

□ Other (specify):

List the name and dosage of any medication the patient is currently taking and how long they have been

taking each medication:

______

Methadone: Length on methadone program: Current dose: ml.

Length of time on current dose:

Prescribing methadone Doctor’s name:

Phone number: ( )

* Licensed Methadone prescribing Physician must indicate on the prescription that Telmexw awtexw trained and designated staff may dispense and witness daily dose.

Medical History: Current health/dental symptoms/conditions/diagnosis:

______

Has patient suffered seizures in the past year: □ Yes □ No

If yes, were these seizures withdrawal related: □ Yes □ No

Office stamp



If no, do they have a seizure disorder: □ Yes □ No

If yes, please describe:

This patient is medically and physically capable of participating in an intensive residential treatment program for substance abuse. Medical Practitioner Name Date Phone Number Fax Number



Prescription Form Dear Medical Practitioner In order to facilitate admission to our program as quickly as possible, we request that you provide written orders for all required medications, to be dispensed one week at time. Methadone prescriptions to indicate that designated Telmexw Awtexw staff will dispense and witness all doses administered. Please write out all orders for a 12-week supply for your patient to cover his/her stay with us. Telmexw Awtexw requires participants to bring originals of all triplicate prescriptions with them for their admission date. If the patient may need any over the counter medications during his stay, please also provide a written standing order for them. We do not accept persons on Methadone Pain Management, we do accept persons on Methadone Maintenance Program. . Date:

Patient Name:

Drug Allergies:

PHNχ: Medication Instructions for Use Days Supply/

Quantity Required over the counter medications:

Medical Practitioner Signature:

Medical Practitioner Name, Please Print:

License #:

Telephone Number: ( ) All medications administered at Telmexw Awtexw (Medicine House) Treatment Centre are dispensed and bubble packed by Agassiz Shoppers Drug Mart, 7130 Pioneer Ave., Agassiz, BCV0M 1A0, (604) 796-2241. All clients are responsible for the cost of their own medication(s).

Office stamp



Employment & Income Assistance or Band Social Development

To: Telmexw awtexw (Medicine House) Treatment Centre Applicant If you are receiving disability or income assistance, please take this form to your worker for completion, and have your Employment & Income Assistance Worker/SA Worker fax it back to our office at 604-796-9839 Please sign the following consent form: I, , consent for any information pertaining to my financial records with the Employment & Income Assistance and or Band Social Development to be shared with Telmexw Awtexw (Medicine House) Treatment Centre. Signed: S.I.N: Dated: To: Financial Aid Worker The bearer of this letter has requested entry into Telmexw Awtexw (Medicine House) Treatment Centre. Comfort Allowance is required to be issued by the client’s home office. If you have any questions please contact the Telmexw awtexw (Medicine House) Treatment Centre Program Manager, Catherine Seymour at 604-796-9829 Client’s Name: Client’s GA number: Is this a regular open file? Is this a Hardship File? Are you aware of any other funds the client is receiving? Workers Name: Phone # Office Location: Fax # Signature Approving Comfort Allowance: DATE: Employment & Income Assistance Program: Phone: Fax:



Legal History Form Clients may not attend court dates while at Telmexw awtexw (Medicine House) except with prior agreement. Clients are expected to not have to attend parole or probation appointments. We do not accept client’s with the following legal conditions: a) Electronic Monitoring, b) Temporary Absence, c) 24 hour supervision, d) day Parole, e) all other legal conditions are reviewed on a case by case basis. If you are on/or previously have been on probation, parole or currently incarcerated, please complete the following. Must include a copy of Probation Order/Conditional Sentence conditions as applicable.

□ Charges Pending □ Parole □ Probation □ Previous History Upcoming court dates: If yes, what were you most recently convicted of?

Sentence Length: □ Conditional Sentence □ CSW □ Probation □ Incarceration

Have you ever served Federal time? □ Yes □ No

Have you ever been charged or convicted of a sexual offence? □ Yes □ No

If yes, have you reached warrant expiry? □ Yes □ No

Date Charge Sentence

Probation/Parole Officer Name: Phone: Fax: If this application is being made from a Correctional Institution, please attach a copy of the client history from Cornet or a copy of his Flimsey file. I consent for Telmexw awtexw (Medicine House) to release and exchange any pertinent information regarding my legal history with any legal agencies associated with me. Signature: Date:



Voluntary Consent for Release of Information

Telmexw awtexw (Medicine House) maintains strict personal confidence rules. Without a written consent to release information, Telmexw awtexw (Medicine House) will neither confirm nor deny that you are in our facility. We do, however, need to speak to certain person(s) or agencies for the purpose of obtaining or providing information that will be helpful to your treatment plan.

Person Name Phone Number Initial

Band Social Worker

EAP Contact

Employer

Counsellor

Mother

Father

Spouse

Family Member

Family Member

Friend

Psychiatrist/Doctor

Mental Health Worker

Lawyer

Social Worker Probation/Parole Office Other

I hereby give Telmexw awtexw (Medicine House) Treatment Centre personnel permission to release and obtain information from the above named individuals. Signature Full Name (Please Print) Date Witness

This consent is valid for 12 months from the date of signing.



Name: DOB

ALCOHOL SCREENING TEST # The following questions are about your alcohol use

during the past 12 months Circle Your Response

1. Do you feel that you are a normal drinker?

YES (0)

NO (2)

2. Do friends or relatives think you are a normal drinker? YES (0)

NO (2)

3. Have you attended a meeting of Alcoholics Anonymous (AA)?

YES (5)

NO (0)

4. Have you lost friends or girlfriends/boyfriends because of your drinking?

YES (2)

NO (0)

5. Have you been in trouble at work because of your drinking?

YES (2)

NO (0)

6. Have you neglected your obligations, your family or your work for two or more days in a row because you were drinking?

YES (2)

NO (0)

7. Have you had delirium tremens (DT’s), severe shaking, heard voices or seen things that were not there after heavy drinking?

YES (2)

NO (0)

8. Have you gone to anyone for help about your drinking? YES (5)

NO (0)

9. Have you been in a hospital because of drinking? YES (5)

NO (0)

10. Have you received a 24-hour roadside suspension or have you been charged for impaired driving?

YES (2)

NO (0)

Total Score

Total scores may range from 0 to 29. Scores of 6 or greater are considered to reflect serious problems with alcohol.



NAME: DOB DRUG SCREENING TEST

# The following questions concern information about your involvement with drugs not including alcoholic beverages during the past 12 months

Circle Your Response

1. Have you used drugs other than those required for medical reasons?

YES (1)

NO (0)

2. Have you abused prescription drugs? YES (1)

NO (0)

3. Do you abuse more than one drug at a time? YES (1)

NO (0)

4. Can you get through the week without using drugs? YES (0)

NO (1)

5. Are you always able to stop using drugs when you want to? YES (0)

NO (1)

6. Have you had “blackouts” or “flashbacks” as a result of drug use? YES (1)

NO (0)

7. Do you ever feel bad or guilty about your drug use? YES (1)

NO (0)

8. Does you spouse (or parents) ever complain about your involvement with drugs?

YES (1)

NO (0)

9. Has drug abuse created problems between you and your spouse or your parents?

YES (1)

NO (0)

10. Have you lost friends because of your use of drugs? YES (1)

NO (0)

11. Have you neglected your family because of your use of drugs? YES (1)

NO (0)

12. Have you been in trouble at work because of drug abuse? YES (1)

NO (0)

13. Have you lost a job because of drug use? YES (1)

NO (0)

14. Have you been in fights when under the influence of drugs? YES (1)

NO (0)

15. Have you engaged in illegal activities in order to obtain drugs? YES (1)

NO (0)

16. Have you been arrested for possession of illegal drugs? YES (1)

NO (0)

17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

YES (1)

NO (0)

18. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc)?

YES (1)

NO (0)

19. Have you gone to anyone for help for drug problem? YES (1)

NO (0)

20. Have you been involved in a treatment program specifically related to drug use?

YES (1)

NO (0)

Total Score Drug Misuse Screening Test Score Problem Severity

0 No Problem 1 – 5 Low level of problems related to drug abuse 6 – 10 Moderate level of problems related to drug abuse 11 – 15 Substantial level of problems related to drug abuse 16 – 20 Severe level of problems related to drug abuse



ALCOHOL/DRUG HISTORY Alcohol and/or drug misuse is considered to be misuse if you have tried any of the following more than two times in order for the mood-altering effect. Please put a circle around the primary drug(s) of choice i.e. primary drug of choice is the one that is causing you the most difficulty in your life.

TYPE

Age of first use

Frequency/How often used: Daily/wkly/ monthly

Amount/ Quantity

Method of Use Inject/smoke/ injest/snort

Date of last use M/D/Y **NOTE: Put a circle around primary

drug(s) of choice

Alcohol (eg. beer, wine, hard liquor) Cannabis (e.g. pot, hash) Cocaine (e.g. crack, coke) Hallucinogen (e.g. acid, mushrooms, PCP, ketamine)

Barbiturate (e.g. phennies, yellow jackets)

Amphetamine (crystal meth, ecstasy, speed)

Heroin (eg. china white, crank) Opiate (eg. morphine, codeine, opium) Inhalant (e.g. glue, hairspray) Illicit Methadone Benzodiazepine (eg, sleeping pills, tranquilizers)

Over the Counter Drugs (e.g. cough syrup)

Other Prescription Drugs (eg. T3’s, Valium)

Tobacco Aftercare: Do you have safe accommodations after treatment? □ Yes □ No If yes, please explain: In the event of an early discharge, will you be returning to a safe environment? □ Yes □ No If you are discharged early, do you have funding arranged to return home? □ Yes □ No Telmexw awtexw (Medicine House) provides a Discharge Summary for clients who have participated in our program. If a Discharge Summary is requested, please indicate to whom &where it should be faxed. Name: Agency:

Fax: ( ) Phone: ( )



TELMEXW AWTEXW (MEDICINE HOUSE) – CLIENT CONTRACT FOR METHADONE MAINTENANCE PROGRAM (To be reviewed and signed in presence of Licensed Methadone Prescribing Physician) Client Name: D.O.B.: This contract shall be between _______________________ and “Telmexw awtexw (Medicine House).” I recognize that I come to the Treatment Centre stabilized on a Methadone program. My start date on Methadone was ______________ and my doseage is . My treating physician is Dr. ___________________ of __________________________

phone number____________________.

I accept that I have an opiate dependency and wish to continue my Methadone while at the Telmexw awtexw (Medicine House) Treatment Centre. I agree that while at the Centre I will receive my Methadone prescriptions from the Centre’s designated staff and/or licensed methadone prescriber. My goal is to avoid all addictive substances other than Methadone, which I will use only as directed. The Methadone maintenance program at Telmexw Awtexw (Medicine House) is based on the Protocols from the College of Physicians and Surgeons of British Columbia. I agree to adhere to the program as detailed to me upon orientation to the facility. I understand that my failure to participate in the program as outlined will result in a review of my suitability stabilization for the treatment program. Depending upon the outcome of this review, I may be required to leave. I understand that the Telmexw Awtexw (Medicine House) Treatment Centre has ZERO TOLERANCE for the following:

A) Use or intended use of mood altering substances. (Possession of any substances Including alcohol, cannabis, heroin, other opiates, illicit methadone, cocaine, amphetamines, barbiturates, PCP, hallucinogens or mood altering medication of any sort staff has not given approval for).

B) Illegal or illicit activities conducted while in treatment, and I agree to Consent to supervised urine samples for drug screening as requested. Failure to comply will result in termination of the program.

I agree to have my Methadone dispensed daily at a pre-determined time through the Telmexw awtexw (Medicine House) Treatment Centre’s designated staff and/or licensed methadone prescriber. I will swallow my Methadone, witnessed, as per the protocols. I agree to sign the College of Physicians and Surgeons of British Columbia release of confidential Information form which I understand allows Telmexw awtexw (Medicine House) Treatment Centre to access my personal medication profile at any time. I agree to see the Telmexw awtexw (Medicine House) Methadone Prescribing Physician and confirm I am not on the Methadone Pain Management Program as required. Licensed Prescribing Methadone Physician: Date: Client Signature: Date:



(complete form with your methadone prescribing physician)

CONSENT TO ATTEND AND PARTICIPATE IN TREATMENT

I, (Client’s Name, PLEASE PRINT) , consent to attend and participate at Telmexw awtexw (Medicine House) and I have reviewed the following points with my A&D Referral Worker and initialed as confirmation of my understanding of the following points:

1. I understand that if I do not have 7 days free from ALCOHOL & drugs, I may be immediately discharged from the program (excluding physician monitored methadone treatment).

2. I understand an incomplete application and lack of supporting documentation delays in the processing of my application and confirmation of an intake date.

3. I consent to the Telmexw awtexw (Medicine House) Staff contacting referral agencies, such as Medical Practitioner’s, Probation Officers, etc. to obtain clarification on information included in my application for treatment. If on provincial assistance, I agree the Telmexw awtexw (Medicine House) Staff can release confirmation of my intake and discharge dates to my Employment and Assistance Worker.

4. I understand if I have legal issues, a copy of the probation order must be submitted with the application for treatment, and ALL pending court dates must be dealt with prior to admission to Telmexw awtexw (Medicine House),

5. I understand the Program Manager or designate will notify my referral worker by letter to confirm my acceptance to treatment.

6. While in treatment, I understand that if I need medical attention, I will be attended to by the proper personnel and/or transferred to an appropriate facility.

7. I understand the importance of being free from and have taken care of all outside business, which would take my attention away from my treatment program.

8. I understand if I am discharged or voluntarily leave treatment that Social Assistance and First Nations Inuit Health Branch will not cover my return travel and that I am responsible for return travel. My return travel arrangements will be arranged prior to my treatment arrival.

9. I have reviewed and completed this application for treatment with my referral worker, all questions and information provided is truthful and thorough to the best of my ability.

Client Signature

Date

Referral Agent Signature

Date



TRAVEL FORM This form is to be filled out by the person responsible for the return travel costs for the client. Telmexw awtexw (Medicine House) Treatment Centre of the Chehalis Indian Band is a non-profit organization and is unable to pay for travel costs. I, __________________________(print name) agree to pay for client travel costs incurred by ________________________ (client’s name) for clients travel to treatment and their return upon discharge. I understand that if the client is discharged or voluntarily leaves treatment that Social Assistance and First Nations Inuit Health Branch will not cover return travel.

In the case that Telmexw awtexw Treatment Centre must pay for the client’s travel, I agree to reimburse Telmexw awtexw Treatment Centre for all costs incurred.

Signed: _________________________ Date: __________________________

Address: _________________________ Phone: _________________________

City: ____________________________ Prov: _____

Postal Code: ______________



Info Only Please retain for your self and/or client DRIVING DIRECTIONS TO TELMEXW AWTEXW Total Time: 1 hour 43 minutes Total Distance: 65.56 miles A: Vancouver, BC 1: Start out going EAST on W 12TH AVE toward YUKON ST. 2.4 mi

2: W 12TH AVE becomes S GRANDVIEW HWY. 1.9 mi

3: Merge onto PROVINCIAL ROUTE 1 E/TRANS CANADA HWY E. 9.6 mi

4: Take the HWY-7 exit, EXIT 44, toward PORT COQUITLAM/PITT MEADOWS

/MAPLE RIDGE. 0.2 mi

5: Take UNITED BLVD ramp toward PITT MEADOWS/MAPLE RIDGE. 0.4 mi

6: Keep LEFT at the fork in the ramp. 0.1 mi

7: Turn SLIGHT RIGHT onto MARY HILL BYP/PROVINCIAL ROUTE 7B. 4.4 mi

8: Take HWY-7 E ramp toward PITT MEADOWS/MAPLE RIDGE/MISSION. 0.1 mi

9: Turn SLIGHT RIGHT onto LOUGHEED HWY/PROVINCIAL ROUTE 7 E. 6.5 mi

10: Turn RIGHT onto HANEY BYP. 1.6 mi

11: Turn SLIGHT RIGHT onto LOUGHEED HWY/PROVINCIAL ROUTE 7 E. 20.1 mi

12: Turn RIGHT onto LOUGHEED HWY/PROVINCIAL ROUTE 7. 6.7 mi

13: Turn RIGHT to stay on PROVINCIAL ROUTE 7/LOUGHEED HWY. 7.6 mi

14: Turn LEFT onto MORRIS VALLEY RD. 3.1 mi

15: End at 16300 Morris Valley Road , Sts’ailes Lhawathet Lalem Healing Centre,

Fraser Valley, BC V0M 1A1

B: 16300 Morris Valley Road, Sts’ailes Lhawathet Lalem Healing Centre, Fraser Valley, BC V0M Turn right follow dirt road to the end Arrive at Telmexw awtexw (Medicine House) Treatment Centre Total Time: 1 hour 43 minutes Total Distance: 65.56 miles


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