Telmexw Awtexw Residential Treatment Program Referral Package Overview. 1. Information about our program- Eligibility Criteria/Program Guidelines/Map

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1 Telmexw Awtexw Residential Treatment Program Referral Package Overview This referral package includes the following: 1. Information about our program- Eligibility Criteria/Program Guidelines/Map 2. An Application for Admission Form. 3. A Pre-Admission Medical Status Form and Prescription Form to be completed by a medical practitioner. 4. A Payment Information Form and Human Resources Funding Form (complete only one depending on your funding source). 5. A Legal History Form to be completed by anyone with a criminal history. 6. A Voluntary Consent to Release Information Form if there are individuals that you would like to share information with. 7. A Client Check List. 8. A Client Contract for Methadone Maintenance Program. 9. A Travel Form to be completed with your referral worker to cover return travel. 10. Consent to Attend and Participate in Telmexw Awtexw Treatment program. Once you have completed the necessary forms, submit them to (by fax or mail; the information is located at the top of this page). Have your Medical Practitioner complete the medical forms, then forwarded to us. You must submit written confirmation of a negative TB test result (X ray or skin test within the last twelve months). ONCE ALL YOUR INFORMATION IS RECEIVED, YOU WILL BE CONTACTED AND GIVEN AN ADMISSION DATE. If you have any questions or need assistance at any time, please do not hesitate to contact our Admission staff. We look forward to your arrival.

2 Application for Admission 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: ( ) 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: ( ) Page 2

3 Name of Previous Programs Attended and dates Treatment & Counselling History 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, client s clean/sober date: Legal: TE: Clients must be capable of participating in programming upon admission and must not require a medically supervised Detox ( i.e. - alcohol or benzodiazepine withdrawals). 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: ( ) 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 Depression Bi Polar Disorder (Manic Depression) Trauma experiences Chronic Pain Seizures: epileptic or non-specified Page 3

4 In the last year have you attempted suicide? Previous psychiatric hospitalizations? Yes No 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? Dates/Reason: Physical History Yes No 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? ** TE: We recommend any personal cultural/spiritual items or ceremonial belongings are 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 client s primary counsellor and as per Telmexw Awtexw policies 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 Support s, Elders, family, friends etc.,) 3. Does client have a post-treatment appointment set? Yes No Page 4

5 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 bubblepacked in the above-described manner. I agree to pay any cost incurred for my own medications. CLIENT SIGNATURE DATE Page 5

6 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 If no, do they have a seizure disorder: Yes Office Stamp 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: ( ) Page 6

7 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: PHN: Medication Instructions for Use Day s 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) All clients are responsible for the cost of their own medication(s). Page 7

8 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 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 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: Page 8

9 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: Page 9

10 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. Page 10

11 Name: DOB ALCOHOL SCREENING TEST # The following questions are about your alcohol use during the past 12 months 1. Do you feel that you are a normal drinker? YES Circle Your Response (2) 2. Do friends or relatives think you are a normal drinker? YES 3. Have you attended a meeting of Alcoholics YES Anonymous (AA)? (5) 4. Have you lost friends or girlfriends/boyfriends YES because of your drinking? (2) 5. Have you been in trouble at work because of your YES drinking? (2) 6. Have you neglected your obligations, your family or YES your work for two or more days in a row because you (2) were drinking? 7. Have you had delirium tremens (DT s), severe YES shaking, heard voices or seen things that were not (2) there after heavy drinking? 8. Have you gone to anyone for help about your YES drinking? (5) 9. Have you been in a hospital because of drinking? YES (5) 10. Have you received a 24-hour roadside suspension or YES have you been charged for impaired driving? (2) (2) Total Score Total scores may range from 0 to 29. Scores of 6 or greater are considered to reflect serious problems with alcohol. Page 11

12 NAME: DOB DRUG SCREENING TEST # The following questions concern information about your Circle Your Response involvement with drugs not including alcoholic beverages during the past 12 months 1. Have you used drugs other than those required for medical reasons? YES 2. Have you abused prescription drugs? YES 3. Do you abuse more than one drug at a time? YES 4. Can you get through the week without using drugs? YES 5. Are you always able to stop using drugs when you want to? YES 6. Have you had blackouts or flashbacks as a result of drug use? YES 7. Do you ever feel bad or guilty about your drug use? YES 8. Does you spouse (or parents) ever complain about your involvement with drugs? YES 9. Has drug abuse created problems between you and your spouse or your parents? YES 10. Have you lost friends because of your use of drugs? YES 11. Have you neglected your family because of your use of drugs? YES 12. Have you been in trouble at work because of drug abuse? YES 13. Have you lost a job because of drug use? YES 14. Have you been in fights when under the influence of drugs? YES 15. Have you engaged in illegal activities in order to obtain drugs? YES 16. Have you been arrested for possession of illegal drugs? YES 17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? YES 18. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc)? YES 19. Have you gone to anyone for help for drug problem? YES YES 20. Have you been involved in a treatment program specifically related to drug use? 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 Substantial level of problems related to drug abuse Severe level of problems related to drug abuse Page 12

13 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 **TE: Put a circle around primary drug(s) of choice Alcohol (eg. beer, wine, hard liquor) 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 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? If you are discharged early, do you have funding arranged to return home? Yes No 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: ( ) Page 13

14 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: Page 14

15 (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 Page 15

16 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: Page 16

17 Info Only Please retain for yourself and/or client DRIVING DIRECTIONS TO TELMEXW AWTEXW Total Time: 1 hour 43 minutes Total Distance: 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 mi 12: Turn RIGHT onto LOUGHEED HWY/PROVINCIAL ROUTE 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 Morris Valley Road, Sts ailes Lhawathet Lalem Healing Centre, Fraser Valley, BC V0M 1A! B: Morris Valley Road, Sts ailes Lhawathet Lalem Healing Centre, Fraser Valley, BC V0M 1. Turn right follow dirt road to the end 2. Arrive at Telmexw awtexw (Medicine House) Treatment Centre Total Time: 1 hour 43 minutes Total Distance: miles Page 17

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