APPLICATION/ INFORMATION PACKAGE

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1 APPLICATION/ INFORMATION PACKAGE We are glad that you are considering coming to LIFE Recovery. For your safety and well-being, we would like you to understand what our expectations are once you are admitted into our program. LIFE Recovery is a Christian organization that has been helping women for over a decade. You will be kept busy during your stay and we expect that you will fully participate in all aspects of our program. You must be willing to reside in a faith filled, communal setting and follow house rules regarding chores, curfews, health, and safety. Process for Intake There are a few things you will need to do before we can admit you into our program: You will need to have a TB test. This can be done at a public health unit and takes approximately hours for the results. Once you have this please ask the clinic or your physician to fax the results to us at (604) You will need to provide us with information on how your stay will be funded; we will need this information prior to your arrival. Please refer to the Funding section of this package for the details you need. Our program is abstinence based. You are required to have 72 hours of sobriety from alcohol and all narcotics, including prescription narcotics. You will need to confirm that you will be able to fully participate in every aspect of our Christian program. Program Description LIFE Recovery is a non-profit society of British Columbia, licenced to provide abstinence based support and recovery services to women who suffer from alcoholism and drug addiction. We support women who want to recover from addiction by gaining insight about how addiction affects them and through the development of a belief system, a life style and support system that will create and sustain recovery. We assist women to achieve maximum independence, increased self-management and enhanced quality of life, and to successfully return to the community. Each resident s participation in psychosocial support services is in accordance with individual needs and personal goals determined by the resident and her Counsellor. Each resident reviews her needs, goals and services with her Counsellor on an on-going basis, and services are adjusted in accordance with changing needs and goals. Counsellors do not provide assessment or in-depth treatment for mental disorders, trauma, sexual abuse or complex interpersonal issues, even where related to substance use, and assist residents who request such assessment and treatment to access professionally qualified clinical practitioners in the community. There is typically a waitlist for these services. LIFE recovery is an 18 bed supportive residential facility that provides a safe, healthy and non-judgemental environment where residents are respected, acknowledged and recognized for who they are. Services are designed to encourage the development of new coping mechanisms, support networks, healthy lifestyles and independence, within an alcohol and drug free environment.

2 Residents develop and reinforce life skills, interpersonal relationships and independence by working together to maintain their home. Residents take turns preparing meals, cleaning the house, and maintaining the yard. All residents do their own laundry. Residents are responsible to administer their own medications but all medication is kept in a locked secure cupboard in the Counsellor s office. Residents are required to take medication as prescribed in the presence of staff and to sign for medications consumed. Staff will assist by making medications available at indicated times and returning any remaining medication for safekeeping. We do not allow any narcotic or benzodiazepine medication. We are unable to accept clients on the Methadone Maintenance program or Suboxone. LIFE Recovery provides shared accommodation with more than enough room for them to feel at home. There are two lounge areas, a main dining area, nine bedrooms, four bathrooms, a full laundry area, three offices and a large backyard. Bedrooms do not have locking doors, and a locked area is available for limited storage of residents personal belongings. The LIFE Recovery program provides in-house psychosocial support for residents consisting of the following components: One-to-one recovery counselling Step groups based on the 12 Step Philosophy Relapse prevention education Anger management Life skills Additionally, the program includes: Completion of a Life Story and a Drug and Alcohol chart Boundaries Joyce Meyer Art therapy Development of a care plan The First 21 Days is a period of stabilization for the resident. It is our hope that the resident will begin to focus on themselves and their personal recovery and not focus on the externals of their lives. They will be asked to complete a Drug and Alcohol Chart and a Life Story. This will give their Counselor an insight into their history of addiction and their journey. Clients who have been here less than 21 days cannot send or receive mail, nor can they use the house telephone. The exception is if residents are mothers; in those cases we do allow phone calls made to school age children between 5:30pm and 7:30pm (these calls are supervised by staff and are on speaker phone). During the first 3 weeks, residents will be matched up with a primary counselor who will meet with the resident and conduct a Bio/Psycho/Social/Spiritual report. It is also during this stage the residents will begin working on Step One of the 12 Step Program most relevant to them. Some residents may be better suited to the Spiritual Steps. Residents will also be expected to fully participate in all groups, evening/weekend programming, and all scheduled outings with staff present days is a time that residents will be working on the completion of the 12 Step program. Residents must continue to attend all group programming, evening/weekend programming, and all scheduled outings with staff present. Residents will also be required to meet with their primary Counselor at least once every two weeks to discuss their progress and any other issues or concerns that the resident or Counselor may have in regard to the resident s recovery.

3 Residents will now be able to utilize the house phone and be granted phone privileges. They also will be able to leave Life Recovery home without staff present as long as they have a client with them who has resided in the house for over 45 days, and have approval from staff. In addition, residents are now able to receive and send out mail unless approved by counsellors (with the exceptions of mail to and from government and/or correctional institutions). It is during this stage that residents volunteer one 4 hours shift at the Thrift Store, LIFE s Second Chance, which supports the operations of LIFE Recovery days is the same as days with the exception that clients can now leave Life Recovery home on their own with approval from staff. Weekends away from the recovery house are now allowed with approval. The Exit Process Prior to resident leaving Life Recovery s house successfully, they will need to complete both a relapse prevention plan and a recovery plan. Both of these plans will be submitted and discussed with resident and their primary Counselor. Residents will be encouraged to have a support group and will be encouraged to share their plans with the people that they have listed as accountability mentors. Prior to the resident leaving the house, they will be asked to complete an evaluation form and provide feedback on the current program. What to Bring You will need mostly casual clothes, an outfit for Church, and your own personal hygiene products. You are only allowed 2 bags for luggage. If you are on prescription medications, please have enough medication to last for three weeks. Our house doctor visits every two weeks. DO NOT bring cell phones, gaming devices, computers or any device that can access the internet, or any clothing or reading material that is not supportive of recovery (ex. alcohol slogans) or which may be offensive to Christian beliefs (ex. provocative clothing, apparel with skulls, gang logos, etc.). DO NOT bring any personal bedding, as all bedding is provided.

4 APPLICATION (PLEASE PRINT) Date of application: Client Information Name of applicant: Preferred name (if different): Date of birth: Age: Care Card #: Marital status: Sobriety date Address: City: Province: Postal Code: Telephone: Emergency Contact or next of Kin: Relationship: Address: City: Province: Postal Code: Telephone: Does the applicant have any children? YES NO If YES, please complete sections below Children Names (write below) Age (write below) If under 19, what is the child s current living situation? (write below) Please provide any relevant details regarding children:

5 Substance Use History Alcohol Cannabis Crack Cocaine Cocaine Heroin Opioids Benzodiazepines Crystal Meth Amphetamines Hallucinogens Inhalants Drug of Choice? Date Last Used Typical Amount Used Age at First Use Treatment History Please list all treatment programs you have attended Name of program Dates attended Reason for leaving Medical and Psychiatric History Family Doctor: Phone number: Psychiatrist: Phone number: Physical Health Conditions: Do you have an existing diagnosed mental health condition : YES NO If yes: please describe and provide medical documentation. Current Medications and Doses:

6 Capacity to Participate Are you able to participate in recreation and chore duties? YES NO If NO, please explain: Do you have a history of anger mismanagement or aggression: YES NO If YES, please explain: Have you ever attempted suicide or had suicidal thoughts? YES NO If YES, please explain most recent occurrence: Do you have any self-harm or eating disorder tendencies? YES NO If YES, please describe: Do you know of any alcohol or drug addiction in your family history? YES NO If YES, please explain: Legal Are you currently involved in any active cases? YES NO If YES, please explain (include where your case is active):

7 Are you currently on probation or parole? YES NO If YES, please explain (please bring conditions of probation and or bail/order on intake): Do you have a criminal record: YES NO If YES, please explain: Do you have any Special Dietary needs? YES NO If YES, please explain: Authorization I,, have read and fully understand the conditions for admission to the LIFE Recovery program. I authorize LIFE Recovery to obtain any pertinent information required for my admission. I further understand that this is a Christian program and am able to fully participate in all aspects of it. Signed this day of, 20 Signature:

8 FUNDING We require confirmation that funding is in place prior to your arrival. Ministry of Social Development (MSD): If the applicant is on Income Assistance an application can be made to Ministry of Social Development (form attached). Applicants should be aware that their rent will be covered while in treatment for up to three months (to a maximum of $375 per month). Self pay: The applicant must provide a signed letter indicating that she is prepared to pay for the LIFE Recovery program. Payment is required upon arrival at LIFE Recovery. Self-pay applicants are also responsible for paying for all medications while in the program. LIFE Recovery will provide detailed invoices documenting prescription costs. The monthly amount for self-pay clients is $1,500 per month ($50 per day). Extended Benefits through employer: LIFE Recovery requires a letter from the applicant s benefits provider verifying that funding is in place. LIFE Recovery program will be paid by (please check one box below): Ministry of Social Development (MSD): Please complete the form on the next page Self-pay: please submit a letter by fax ( ) from the payee that is dated with the payee signature confirming that they will pay for the program. Payment must be provided upon arrival to LIFE Recovery. Extended Benefits: Please have the Benefits Administrator from the applicant s employer submit a letter by fax ( ) confirming that the program will be paid.

9 MINSITRY OF SOCIAL DEVELOPMENT FUNDING VERIFICATION FORM To: Ministry of Social Development (Office: ) Attention: Fax: Tel: From: LIFE Recovery Tel: (604) Fax: (604) Attention: Administrator Client Name SIN# The above named client has been referred for admission to a qualifying residential addiction program, LIFE Recovery. Prior to admission, the facility requires confirmation that the client s per diem costs (less any non-exempt income) will be paid by MSD while in receipt of, and eligible for, income assistance. Authorization: I,, authorize the Ministry of Social Development to confirm my eligibility for funding, and to release any related information to the above named staff. Client signature Date MINISTRY OF SOCIAL DEVELOPMENT COMPLETE AND FAX TO FACILITY NOTED ABOVE Case #: Client has an open and active MSD file: YES NO Application SR #: Client is ELIGIBLE / INELIGIBLE for funding Client s per diem will be paid by MSD as per current eligibility, less any non-exempt income from other: (If applicable) Less any non-exempt income (monthly amount divided by 30 days) Per Diem Rate $ Non-exempt income from $ MSP Per Diem for Client = $ (If applicable) Nutritional Subsidy: $ per month Completed by: Print name only Signature: Date:

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