treatment centre adult referral package · inclusion criteria carrier sekani family services...

Treatment CentreAdult ReferralApplication Package

Treatment Centre SelectionPlease select which treatment centre(s) you are applying to:

Carrier Sekani Family ServicesP.O. Box 1219Vanderhoof, B.C.V0G 2A0

Telephone: (250) 567.2900Toll-free: 1.866.567.2333Fax: (250) 567.2975

Length: 4-weekOpioid Replacement Therapy: YesFamily Program: NoCouples Program: NoGender: Co-edPregnant: Yes - Only within the 2nd

trimesterAlcohol/Substance free: 14 days

Length: 6-week; 7-week or 8-weekOpioid Replacement Therapy: YesFamily Program: NoCouples Program: NoGender: Men-onlyPregnant: N/AAlcohol/Substance Free: Minor Withdrawal

Length: 6-weekOpioid Replacement Therapy: No Family Program: YesCouples Program: YesGender: Co-ed, Men-only and

Women-only Pregnant: Yes - Only 7 months or lessAlcohol/Substance Free: 3 weeks

Length: 6-weekOpioid Replacement Therapy: No Family Program: NoCouples Program: NoGender: Co-ed; Women-only and

Men-onlyPregnant: NoAlcohol/Substance Free: 14 days

Length: 7-weekOpioid Replacement Therapy: No Family Program: YesCouples Program: YesGender: Co-edPregnant: YesAlcohol/Substance Free: 14 days

Gya’Wa’Tlaab Healing CentreP.O. Box 1018Haisla, B.C.V0T 2B0

Telephone: (250) 639-9817Fax: (250) 639-9815

Kackaamin7830 Beaver Creek RoadPort Alberni, B.C.V9Y 8N3

Telephone: (250) 723-7789Fax : (250) 723-5067

‘Namgis Treatment CentreP.O. Box 290Alert Bay, B.C.V0N 1A0

Telephone: (250) 974-5522Fax: (250) 974-2257

Nenqayni Wellness CentreP.O. Box 2529Williams Lake, B.C.V2G 4P2

Telephone: (250) 989-0301Fax: (250) 989-0307

Once the application is completed, please fax a copy to each Treatment Centre you are applying to.

Length: 45-dayOpioid Replacement Therapy: YesFamily Program: NoCouples Program: NoGender: Co-edPregnant: YesAlcohol/Substance free: 14 days

Length: 6-weekOpioid Replacement Therapy: YesFamily Program: NoCouples Program: YesGender: Co-ed Pregnant: Yes – Only within the 2nd


Length: 40-dayOpioid Replacement Therapy: NoFamily Program: NoCouples Program: NoGender: Co-ed Pregnant: Yes – Only within 2nd


Length: 42-day, 2 eight- week programsOpioid Replacement Therapy: YesFamily Program: YesCouples Program: YesGender: Co-ed, Men-only and

Women-onlyPregnant: Yes - Only within 2nd

trimester Alcohol/Substance free: 14 days

North Wind Wellness CentreBox 2480 Station ADawson Creek, B.C.V1G 4T9

Telephone: (250) 843-6977Fax: (250) 843-6978

Round Lake Treatment Centre200 Emery Louis RoadArmstrong, B.C.V0E 1B5

Telephone: (250) 546-3077Fax: (250) 546-3227

Tsow-Tun Le Lum Society699 Capilano RoadLantzville B.C.V0R 2H0

Telephone: (250) 390-3123Fax: (250)390-3119

Wilp Si’Satxw House of PurificationBox 429Cedarvale-Kitwanga RoadKitwanga, B.C. V0J 2A0

Telephone: (250) 849-5211Fax: (250) 849-5374

OUTPATIENT/COMMUNITY-BASED

Telmexw Awtexw Treatment CentreMailing Address Physical Address4690 Salish Way 16300 Morris Valley RdAgassiz, B.C. Agassiz, BCV0M 1A1

Telephone: (604) 796-9829Fax: (604) 796-9839

Inclusion Criteria

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ier

Seka

ni F

amily

Ser

vice

s

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Tlaa

b H

ealin

g Ce

ntre

Kack

aam

in

‘Nam

gis

Trea

tmen

tCen

tre

Nen

qayn

i Wel

lnes

s Ce

ntre

Nor

th W

ind

Wel

lnes

s Ce

ntre

Roun

d La

ke T

reat

men

t Cen

tre

Tsow

-Tun

Le

Lum

Soc

iety

Wilp

Si’S

atxw

Hou

se o

f Pur

ifica

tion

Opioid Replacement Therapy

Family Program

Couples Program

Pregnant

Co-ed

Men-only sessions

Women-only sessions

Youth-Only sessions

Corrections Programs

Barrier Free (person with disability)

Alcohol-free

Substance-free

√

√√

√

√ √√√

√√√ √√ √√ √

√√√ √√ √

√√

√√√√√√√√√√√√

√

√√ √√ √

√

14Days

14Days

14Days

14Days

14Days

14Days

3Weeks

Minorwith-

drawalMinorwith-

drawal

14Days

14Days

14Days

14Days

14Days

14Days

14Days

3Weeks

14Days

INCLUSION

4 | P a g e Referral Application – February 2019

Personal Information First Name Last Name

Preferred Name: Birthdate (dd/mm/yyyy)

___ /___ /_____

Self-Identified Gender

________

Address City/Town

Province Postal Code On Reserve Off Reserve

Telephone Cellphone (if applicable)

Email

Marital Status Single Common-Law Married

Separated Divorced Widowed

Indigenous Identity Status Non-Status Métis Inuit N/A

Band Name Treaty Community Status Number Personal Health Number

Has applicant been mandated to attend treatment? No Yes If yes, by who? (Please attach any applicable documents)

Funding Resources How is treatment being paid for? Funding resources must be in place prior to attending. (e.g. Corrections, Employer, FNHA, self, etc.)

Does the applicant have funding for travel to and from Treatment?

Emergency Contact

Name Relationship to applicant

Telephone Secondary phone


Referral Worker Information Date of Assessment/Referral

Referral Worker Name Title/Position

Email

Organization/Agency Name Telephone Fax Address City/Town Province Postal Code

Is applicant receiving counselling from you? No Yes

What kind of healing supports has the applicant had in the last three (3) months? Has the applicant completed pre-treatment sessions (e.g., AA, NA, Counselling, etc.) If yes, how many sessions have been completed?

Where does the applicant go in their community for support?

Income What is the applicants’ source of income (employed, social assistance, disability, etc.)?

What is the applicants’ current occupation?

Employed full-time

Employed part-time Retired Seasonal worker

Primary care-taker of children and/or home

Student Unemployed Other (specify): _________________

Education

What is the applicants’ highest level of education completed?

No Formal Education Adult Education Grade completed: ______

College in-progress College Diploma Trade School

University in-progress Bachelor's degree Graduate Degree

(Master's/PhD)


Does the applicant require any supports with reading? No Yes

Does the applicant require any supports with writing? No Yes

Legal

Does the applicant have a history with the legal system? No Yes If yes, please complete the section below.

Does the applicant have any previous convictions/charges/legal involvement? No Yes

If yes, describe, including whether charges were for a violent or sexual offence.

Does the applicant have any current legal orders or legal involvement? No Yes If yes, describe, including whether charges were for a violent or sexual offence.

Is the applicant currently on Parole? No Yes

Is the applicant currently serving a Probation or Bail Order? No Yes

If yes to either, attach any applicable documents and orders.

If yes to either, please provide:

Parole/Probation/Bail Officer Name Parole/Probation/Bail Officer Telephone

Parole/Probation/Bail Officer Email

Address

Does the applicant have any charges pending? No Yes

If yes, describe


Please list any upcoming or pending court dates

Are any legal issues alcohol or drug related? No Yes

Family

Total number of dependent children

Have children been living with their parents? No Yes

If no, who do they live with?

Have children been apprehended, placed in foster care or with a Designated Aboriginal Agency? No Yes

If yes, specify by which organization or agency

Does the family have any type of supervision order from a family protection agency? No Yes Does the applicant have any outstanding child custody issues? No Yes Does the applicant have a no-contact order with his/her partner No Yes

Living Arrangements

What is the applicants’

current living arrangements?

With my family With extended family With parent(s)

Other (specify)

__________

With friends As part of a couple Alone Recovery Home

As a single parent

With partner and kids Homeless Shelter


Wellness Mental

Does the applicant have a history of or have you ever been diagnosed with a mental illness by a medical professional? No Yes

If yes, specify Attach assessment if available.

Does the applicant have a history of suicidal ideation? No Yes

Does the applicant have a history of self-harm? No Yes

Has the applicant ever attempted suicide? No Yes If yes, when was the last attempt?

Emotional

Did the applicant attend Indian Residential School? No Yes Is the applicant an Intergenerational survivor of Indian Residential School? No Yes

Physical

Does the applicant have any chronic or acute medical issues that could affect their participation in the program?

No Yes

Does the applicant have any special needs that the treatment centre should be aware of (e.g. visual impairments, hearing aids, etc.)

No Yes

Does the applicant have any physical disabilities that the treatment centre should be aware of? (e.g. require wheelchair accessible rooms, etc.)

No Yes

If yes, please explain.


Spiritual Please share any spiritual or cultural involvement that the applicant take part in.

Is the applicant willing to respect First Nations healing practices and incorporate spirituality into your healing (e.g. Sweat Lodge, Cedar Brushing, Pipe Ceremony, etc.)? No Yes


Substance Use History Please circle primary drug(s) of choice

Drug Type Age of first use

How often (rarely, occasionally

monthly, weekly, daily)

Amount/Quantity used Date of Last Use

Alcohol

Amphetamine

Cannabis

Crystal Meth

Crack Cocaine / Cocaine Powder

Hallucinogens

Heroin

Inhalants

Opiates

Opioid Agonist Treatment (ex.

Methadone, Suboxone)

Prescription Drugs

Tobacco

Process addiction (e.g. gambling,

eating): _____________

Other (specify): _____________

Other (specify): _____________


Treatment History Has the applicant attended inpatient substance use treatment before? No Yes If yes, please fill in the following

Name of previous treatment centre Dates Did he/she complete program?

No Yes

No Yes

No Yes

Has the applicant participated in outpatient or community-based healing programs? No Yes If yes, explain

Opioid Agonist Treatment (OAT) Only to be completed by those currently on Opioid Agonist Treatment and applying to treatment centres that accept applicants on OAT. Opioid Agonist Treatment prescribing Physician or Nurse Practitioner: Please provide contact information

Physician Name

Telephone Number Fax

Address

History of Opioid Agonist Treatment

Length of Opioid Agonist Treatment Specify Replacement Type (e.g., Methadone, Suboxone, etc.) Initial dose (mg) Current dose (mg) Length of time on current dose:


Medical Assessment - Must be completed by medical personnel (e.g., Physician, Nurse Practitioner, Registered Nurse) Please print clearly.

Date of Assessment/Referral

Applicant's Name Date of Birth (dd/mm/yyyy) ___/___/_____

Personal Health Card Number Status Number

Specify any dietary requirements (allergies, intolerances, diabetes, etc.)

Current Medications (names)

Dose (ml/mg)

Reason for Taking How long has applicant been taking medication?

I, _________________________ (applicant’s name), hereby request and authorize

____________________________ (Physician, Nurse Practitioner or Registered Nurse’s name) to

release medical information pertaining to myself to First Nations Health Authority Funded

Treatment Centre and to the Referral Agent acting on my behalf.

Applicant’s Signature: ______________________________________

Medical Personnel’s Position/Title: _____________________________________

Physician, Nurse Practitioner or Registered Nurse’s Signature:

___________________________

Date: ______________________________


Medical History Comments Does the applicant have any communicable diseases?

No Yes

Has the applicant been tested for Tuberculosis? (Note: a TB test is required for Admission.)

No Yes

Date of test: ________________ Results: Negative Positive Please attach test results and, if positive, chest x-ray results

Does the applicant have any head trauma or cognitive impairment? No Yes

Does the applicant have a history of seizures? No Yes

Does the applicant have any chronic illnesses or conditions?

No Yes

Does the applicant have any cardiovascular disorders or conditions? No Yes

Does the applicant have any severe allergies? No Yes

Does applicant require an Epi-Pen or Ana-Kit? No Yes

Is the applicant pregnant? If yes, how many weeks.


Consent for the Release of Pre-Treatment Information Release of confidential information between treatment centre staff and other organization or agencies. I _____________________________ (print applicant’s name), hereby give permission for the ________________________________ (treatment centre) staff to contact the identified individuals listed below for the release of information in regard to pre-treatment information and attendance verification.

_______________________ Referral Worker

________________________ Organization

Email: ___________________

Phone: __________________

Fax: ____________________

________________________ Alternative Referral Contact

________________________ Organization

Email: ___________________

Phone: __________________

Fax: ____________________

________________________ Individual #3

________________________ Organization

Email: ___________________

Phone: __________________

Fax: ____________________

________________________ Individual #4

________________________ Organization

Email: ___________________

Phone: __________________

Fax: ____________________

Client Signature: Date:

Referral Worker's Signature: Date:

NOTE: This form is applicable for one year after signed and dated. The Client may change or revoke this release at any time by giving notice to the Treatment Centre in writing.


Consent for the Release of Treatment Information Release of confidential information between treatment centre staff and other organization or agencies. I _____________________________ (print applicant’s name), hereby give permission for the ________________________________ (treatment centre) staff to contact the identified individuals listed below for the release of information in regard to attendance verification, progress during treatment, aftercare planning, and/or final discharge report.

_______________________ Referral Worker

________________________ Organization

Email: ___________________

Phone: __________________

Fax: ____________________

Pre-Treatment Information Attendance Verification Progress during Treatment Aftercare Planning Final Discharge Report

________________________ Individual #2

________________________ Organization

Email: ___________________

Phone: __________________

Fax: ____________________


________________________ Individual #3

________________________ Organization

Email: ___________________

Phone: __________________

Fax: ____________________


________________________ Individual #4

________________________ Organization

Email: ___________________

Phone: __________________

Fax: ____________________


NOTE: This form is applicable for one year after signed and dated. The Client may change or revoke this release at any time by giving notice to the Treatment Centre in writing.

Client Signature: Date: Referral Worker's Signature: Date:


Appendix A: Dependents Only to be completed by those applying to treatment centres with family programs.

How many children will be coming to treatment?

List the name(s) and age(s) of the dependents attending treatment with parent:

Name Age

Dependent #1

Dependent #2

Dependent #3

Describe a care plan and caregiver for unattended children:

How long has applicant been married or in current relationship?

Will partner be attending? No Yes

Does partner have substance misuse issues? No Yes Does partner receive A&D counselling? No Yes

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