New Port Centre. 5. DHQ Drug History Questionnaire 6. Adverse Consequences Questionnaire 7. Tracking Sheet With Scores of Other Provincial Assessments

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1 New Port Centre Page 1 of 2 NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne ON, L3K 2N7 Phone (905) Ext Fax: (905) Web : A D M I S S I O N I N F O R M A T I O N General Admission Information for Residential Treatment Referrals to our residential services are accepted from drug and alcohol treatment providers. New Port Centre does not accept self-referrals. For information on drug and alcohol treatment providers in your area, contact the Ontario Drug and Alcohol Registry of Treatment (DART) by phone at or visit their website ( Referrals to New Port Centre can be made by fax or mail only. To make a referral to our residential services, have your treatment provider complete and forward a New Port Centre Intake Package to our Intake Department. The Intake Package can be downloaded from our website: A complete referral includes all 7 of the following: New Port Centre Intake package forms 1. New Port Centre Intake Form (1 page) 2. New Port Centre Medical Profile (2 pages) to be completed by a physician 3. Legal History Questionnaire 4. n-smoking Agreement Completed Provincial Assessment Tools 5. DHQ Drug History Questionnaire 6. Adverse Consequences Questionnaire 7. Tracking Sheet With Scores of Other Provincial Assessments Please call our Intake Coordinator at , Extension if you have any questions regarding your referral to New Port. REFERRALS WILL BE PROCESSED WITHIN SEVEN (7) WORKING DAYS FROM RECEIPT The client will be notified after review of the file by our Intake Coordinator The Medical Profile Form must be completed by a physician and list all prescription and non-prescription medication (including vitamins) that the client plans to take during their residential treatment stay. When coming to New Port for residential treatment, clients should bring their valid Ontario Health Card and proof of drug benefit eligibility. We expect people attending residential treatment to be neither under the influence of non-prescribed drugs or alcohol, nor experiencing any withdrawal symptoms. If a person is assessed as being medically unstable, they will be directed to NHS withdrawal management services for assessment before admission. If a person is assessed as being under the influence of a mood-altering substance and attempts to operate a motor vehicle, we are obligated to notify the police. Revised vember

2 Page 2 of 2 A D M I S S I O N S I N F O R M A T I O N Information For People On Methadone On admission day, please have your daily methadone drink before you arrive. Your prescription should be dated to begin the day after admission and to end on the last day of treatment. Methadone script must be faxed to Boggio Pharmacy prior to your admission date. Information For Prescribing Physicians If your patient is being referred to New Port Centre residential services, please complete a Medical Profile Form for them. The Medical Profile Form must detail all prescription and non-prescription medication (including vitamins) that your patient plans to take while in residential treatment. When New Port Centre has confirmed a residential admission date for your patient, please fax an 18-day prescription for all medications to Boggio Pharmacy prior to that date. Also, please arrange for Boggio Pharmacy to receive an original copy of ANY prescriptions containing narcotics (your patient can bring this copy with them on admission day). Boggio Pharmacy will blister pack the medication and charge a dispensing fee at applicable rates. Boggio Pharmacy Phone: Catharine Street Fax: Port Colborne, ON L3K 4K8 Alternately, please have your patient s pharmacy blister pack 18 days worth of prescription medication for their residential stay. Vitamins and other non-prescription medication should be blister packed and authorized by the doctor who completes the Medical Profile Form. Information For Correctional Services Referrals New Port Centre and the Ontario Ministry of Community Safety and Correctional Services and Correctional Service of Canada co-operate to offer treatment for substance use to people involved in the correctional system. New Port Centre does not accept self-referrals. Correctional services should complete and forward a New Port Centre Intake Package with Provincial standardized assessment information to our Intake Department. In addition, signed consent to share information between New Port Centre and Correctional Services is required. When such consent is received, New Port Centre will contact Correctional Services to collect information in order to appropriately assess the person s suitability for our residential treatment program. This information includes background charges, conduct and attendance at programming during incarceration and any concerns regarding violence, anger, non-compliance or lethality. Revised vember 5, 2010

3 New Port Centre Fax# (905) Niagara Health System Port Colborne General Site 260 Sugarloaf Street, Port Colborne, ON, L3K 2N7 Phone: (905) Ext Fax: (905) on.ca W eb: www. niagarahealt h.on.ca/services/addiction-recovery I N T A K E F O R M Referral Date / / ( D D / M M / Y Y ) NPC Client # Client First Name: In Patient Program: Client Last Name: Out Patient Program: Date of Birth: (DD MM - YY) Current Problem Substances Gender: Male / Female 1. Last Name at Birth: 2. # Days Used in Last Month Home Phone: ( ) 3. Address: Apt 4. City, Province: 5. Postal Code: I.D. Agency When Calling: / If : Referral Agency: Referral Agent Name: Referral Phone: ( ) Health Card #: Ver: Ethnicity: Substances Used in Last Year (check all that apply) ne Alcohol Amphetamines Barbiturates Benzodiazepines Cannabis Cocaine Crack Crystal Meth Ecstasy Glue / Inhalants Hallucinogens Heroin / Opium OTHER Psychoactives OTC Codeine Prescription Opioids Steroids Tobacco Next of Kin: Relation: n medical Injection Drug Use (Circle ONE only) Next of Kin Phone: ( ) 1. Never Injected Ever Married: / 2. Injected prior to 1 year ago Current Marital Status: 3. Injected in last year Highest Education: Employment: Full Part Looking t looking Source of Income: Physical Health Hospitalizations # of overnight hospitalizations last year Mental Health History Legal Issues: / Type: Diagnosed w Young Offender: / Mandated Admission: / If yes: CAS / Court / Work / Family Diagnosed in Lifetime Hospitalized Last year Hospitalized in Lifetime Counselling/Support/Tx w Family Doctor: Counselling/Support/Tx in Last Year Dr. Phone: ( ) Psychiatrist: Psych Dr. Phone: ( ) Counselling/Support/Tx Ever Prescribed Medication w Prescribed Medication in Last Year Prescribed Medication - Ever Taking Methadone Mental Health Diagnosis & Prescribed Meds: Visual Impairment Hearing Impairment Mobility/Physical Impairment Pregnant Gambling Problem A New Port Centre Medical Profile Form must be received before an In Patient bed date is assigned Date Last Revised vember 5, 2010

4 New Port Centre NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne ON, L3K 2N7 Phone (905) Ext Fax: (905) Web : Dear Doctor/Nurse Practitioner: Your patient has applied for admission to the residential component of treatment for treatment of his/her addiction(s) at the New Port Centre. The New Port Centre is a non-medical, non-psychiatric treatment centre for substance abuse. As a non-medical, non-psychiatric facility, we require the thorough and accurate completion of the enclosed Medical Profile to ensure that it is consistent with the medications that the client has been prescribed. For example, if a patient is taking an antidepressant, we would consider that the patient suffers from depression and that would be considered a psychiatric disorder. The list of current medications must be legible and complete on the Medical Profile form provided i.e. correct medication, correct dose, correct time and the correct route that the medication should be given. New Port addiction counsellors are non-medical personnel and it is essential that all information be complete. We have no access to psychiatric consultation other than the local emergency department; therefore we ask that clients be deemed stable with any psychiatric condition that they may have been diagnosed with, before attending New Port Centre. Inaccurate, incomplete, non-legible medical profiles will delay the intake process for your patient. Many thanks for your attention to these vital safety issues. Sincerely, Management, New Port Centre Revised: v 5, 2010

5 New Port Centre Fax# (905) Niagara Health System Port Colborne General Site 260 Sugarloaf Street, Port Colborne, ON, L3K 2N7 Phone: (905) Ext Fax: (905) on.ca Date Completed / / ( D D / M M / Y Y ) Client Name NPC Client # Page 1 of 2 W eb: www. niagarahealt h.on.ca/services/addiction-recovery Revised: v M E D I C A L P R O F I L E F O R M Two-page form to be filled out by the Patient s Family Doctor and sent back to the New Port Centre before assignment of residential bed date. I, (Please Print Patient Name), hereby, give: a) Authorization to my family doctor, Dr., to release any and all pertinent medical information related to my present medical condition to the New Port Centre. I also acknowledge that this is not an insured service and that any costs incurred are my responsibility. b) Authority to permit New Port Centre counsellors, when necessary, to inspect my file and receive information relevant to my medical care. Date Signed: Patient Signature: Witness: (please print) Patient Information Patient First Name: Patient Last Name: Date of Birth: (DD/MM/YY) Gender: Male / Female Witness Signature: Medical Information Pregnant: / Psychiatric History: / Psychiatric Diagnosis: Psychiatrist: Dr. Maiden Name: Psych Dr. Phone: ( ) Home Phone: ( ) Psych Dr. St. Address: St. Address: City, Prov.: Postal Code: Psych Dr. City, Prov.: Psych Dr. Postal Code: Have you been immunized for? Health Card #: Hepatitis B: #1 Year: Version Code: / #2 Year: Drug Eligibility Card: / Drug Plan Name: Tetanus / Diphtheria: (In last ten years) Drug Plan #: / Year: Regular Pharmacy: Have you been tested for? Name: HIV: / Year: Street: Result: City: Hepatitis: / Year: Phone: ( ) Result: Family Doctor: Dr. Phone: ( ) Dr. St. Address: Dr. City, Prov.: Dr. Postal Code: Recent Medical Care (DD/MM/YY) / / / / / / / / / #3 Year: Last Completed Medical / Physical Exam Last Pap Smear (females) Last Doctor s Appointment Recent Hospitalizations (describe):

6 New Port Centre Fax# (905) Niagara Health System Port Colborne General Site Date Completed / / ( D D / M M / Y Y ) Client Name 260 Sugarloaf Street, Port Colborne, ON, L3K 2N7 NPC Client # Phone: (905) Ext Fax: (905) Page 2 of 2 on.ca W eb: www. niagarahealt h.on.ca/services/addiction-recovery Revised: v M E D I C A L P R O F I L E F O R M T H I S S E C O N D P A G E T O B E C O M P L E T E D B Y F A M I L Y P H Y S I C I A N Current Medications (Include all Prescription and n-prescription Medication) Medication Name Daily Indication (Please Print) Dosage # Mths on Med Patient Stabilized / / / / / / / / / Of the Medications Listed above, are there any that put the patient or others at risk by omitting? (If yes explain): / Patient History of YES NO If YES please specify Allergies to Medication Allergies to other Stimulants Psychiatric Disorder Suicide Attempt Seizures Physical Limitations Other Significant Problems Heart Disease Liver Disease Stomach Problems Stroke / Paralysis High Blood Pressure Rheumatic Fever Tuberculosis Kidney Disease Diabetes Pancreatitis Hallucinations (w/o drugs) Delirium / Tremens Sexually Transmitted Disease I, Dr. have reviewed this two-page medical profile form and consider this patient medically and pharmacologically stable enough to adequately function in a non-medical residential setting. Date: (DD/MM/YY) Physician Signature: Office Stamp Here: Physician Name: (print)

7 New Port Centre NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne ON, L3K 2N7 Phone (905) Ext Fax: (905) Web : L E G A L H I S T O R Y F O R M Client Name: Have you ever been charged with a Federal or Provincial Offence? If yes, indicate the date and describe the offence and disposition: Date Offense (Charge) Disposition (Outcome) Are you presently on Probation or Parole? If, Start Date Expected End Date Contact your Probation/Parole Officer to complete a consent form (consent to share information) and fax it to New Port Centre Intake Department at Revised vember

8 New Port Centre NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne ON, L3K 2N7 Phone (905) Ext Fax: (905) Web : NON-SMOKING POLICY AGREEMENT FORM I, am aware that the New Port Centre is an (Print Name) abstinence based substance abuse treatment facility including nicotine and as a client I agree to the following: a) To respect the non-smoking policies of the New Port Centre/Niagara Health System b) To arrive for my admission date a minimum of 5 days tobacco free c) To arrive for my admission with enough Nicotine Replacement Therapy aids for my stay in residential treatment (i.e. nicotine patches, gum, lozenges or inhalers). I am aware that the decision to smoke in the building or on the property of the Niagara Health System will jeopardize my ability to remain in the program and may result in discharge from the program. I am aware that to assist me in being tobacco free, the New Port Centre will offer access to acupuncture, impact of smoke inhalants education sessions, individual counselling and relaxation therapy techniques. Signature: Date: Witness: Revised vember 5, 2010

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