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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
trimesterAlcohol/Substance free: 14 days
Length: 40-dayOpioid Replacement Therapy: NoFamily Program: NoCouples Program: NoGender: Co-ed Pregnant: Yes – Only within 2nd
trimesterAlcohol/Substance free: 14 days
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
Carr
ier
Seka
ni F
amily
Ser
vice
s
Gya
’Wa’
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)
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
5 | P a g e Referral Application – February 2019
Referral Worker Information Date of Assessment/Referral
Referral Worker Name Title/Position
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)
6 | P a g e Referral Application – February 2019
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
7 | P a g e Referral Application – February 2019
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
8 | P a g e Referral Application – February 2019
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.
9 | P a g e Referral Application – February 2019
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
10 | P a g e Referral Application – February 2019
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): _____________
11 | P a g e Referral Application – February 2019
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:
12 | P a g e Referral Application – February 2019
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: ______________________________
13 | P a g e Referral Application – February 2019
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.
14 | P a g e Referral Application – February 2019
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.
15 | P a g e Referral Application – February 2019
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: ____________________
Pre-Treatment Information Attendance Verification Progress during Treatment Aftercare Planning Final Discharge Report
________________________ Individual #3
________________________ Organization
Email: ___________________
Phone: __________________
Fax: ____________________
Pre-Treatment Information Attendance Verification Progress during Treatment Aftercare Planning Final Discharge Report
________________________ Individual #4
________________________ Organization
Email: ___________________
Phone: __________________
Fax: ____________________
Pre-Treatment Information Attendance Verification Progress during Treatment Aftercare Planning Final Discharge Report
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:
16 | P a g e Referral Application – February 2019
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