Sunshine Coast Health Center. Admission Package. Part 2 of 2

Transcription

1 Sunshine Coast Health Center Admission Package Part 2 of 2

2 Welcome Whether this is for yourself, a family member, loved one or employee, thank you for choosing Sunshine Coast Health Center. This collection of forms and information is Part 2 of the Client Package and will assist in registering and preparing for the men s Primary Program. Agreement of Responsibility for Residential Treatment Costs... 3 The Agreement of Responsibility for Residential Treatment Costs is to be reviewed, signed and submitted by the individual covering the cost of treatment. This may be the client applying for admission to the Residential Program or it may be a family member, spouse/partner or employer. Please note this form needs to be completed 24 hours prior to admission. Agreement of Responsibility for Client Personal Expenses... 4 The Agreement of Responsibility for Client Personal Expenses is to be completed by the party that has agreed to pay for personal expenses incurred during a client s stay in the Residential Program. Please refer to the Fee Schedule on Page 5 for a complete review of costs reflecting what is covered in the Residential Program fee. Fee Schedule... 5 Pre-Admission Checklist (Things to bring/not to bring)... 8 The Pre-Admission Checklist will help you pack for your stay at Sunshine Coast Health Center. A list of things to bring and not to bring is provided as well as information on sending/receiving mail, laundry facilities, client chores and visitor hours. Client Admission Form (see Admission Package Part 1 of 2) The Client Admission Form (*) is a document the clinical staff requires prior to admission. Critical information such as patient contact information and the client s history (medical, psychological, alcohol/ drug use, past treatment, employment, etc.) is reviewed by the Nursing Supervisor to ensure that the client is a good fit for the program. Further information, including travel arrangements, can be found on our website at 2

3 AGREEMENT OF RESPONSIBILITY FOR RESIDENTIAL TREATMENT COSTS I, agree to pay Sunshine Coast Health Centre (2005) Ltd. for the full cost of residential treatment ( the Program ) for as follows: (name of client) Tick program (at left in table) that applies to you. Duration Semi-Private Semi-Private Daily Rate ADDICTION PROGRAM Private Private Daily Rate 30 day $15,960 $532 $20,760 $ day $21,420 $510 $28,140 $ day $29,700 $495 $39,300 $ day $39,600 $440 $54,000 $600 DETOX ONLY PROGRAM 7 days $6,580 $940 N/A N/A FAMILY & COUPLES PROGRAM (lodging not included) Family Program Couples Program 1 Free Free ALUMNI PROGRAM 2 14 day $5,530 $395 $7,770 $ day $11,850 $395 $16,650 $ day $23,700 $395 $33,300 $555 SOBER LIVING 3 14 day $1,708 $122 One month $2,800 $91 TRAUMA PROGRAM 30 day $22,170 $739 $26,970 $ day $27,680 $659 $34,400 $ day $35,760 $596 $45,360 $ day $49,410 $549 $63,810 $709 All Fees are GST and PST exempt. Most fees can be claimed with Revenue Canada see your accountant for advice on your particular situation. Prices subject to change without prior notice. 1) Couples Program participants must first complete the Family Program. Both events are run on consecutive days. Please note that the Couples Program is not a residential program for couples; Sunshine Coast Health Center is strictly an all-male residential facility. 2) Minimum stay in the Alumni Program is 14 days. Clients in the Alumni Program must have previously attended our program. A surcharge of $150 will be charged for each night of required detox care. 3) Sober Living available only to clients who have completed the Addiction or Trauma Programs. Continued on next page 3

4 AGREEMENT OF RESPONSIBILITY FOR RESIDENTIAL TREATMENT COSTS (cont d) I further agree to reimburse for additional costs incurred during the Program. Additional costs may include, but are not limited to, the following: prescriptions, off-site adjunct therapy, emergency dental work, post-discharge travel, and missed appointments with the psychiatrist or Medical Director (see page 5 for details). Clients who do not have valid provincial health plan coverage 3 will be charged for doctor visits, psychiatrist visits, and lab work. Payment for additional fees is due prior to client discharge. Credit card information should be recorded below for this purpose. 3) Clients with overdue provincial health insurance premiums, clients residing outside of Canada, or residents of Quebec Refund Policy: By signing this document, I understand that Sunshine Coast Health Centre expects the client to complete the Program. As part of this understanding, I am expected to promptly advise Sunshine Coast Health Centre staff if a client expresses any intent to leave the Program early. Furthermore, I agree to support all reasonable efforts made by Sunshine Coast Health Centre staff to keep a client engaged in the Program. If a client, despite all efforts by staff, leaves the Program early, any refund will be negotiated directly between myself, as Payer, and the Administrator on behalf of Sunshine Coast Health Centre. Sunshine Coast Health Centre will notify the appropriate individual who is paying for the client s stay in case of early discharge. I understand that refunds are not provided on a pro rata basis since daily average rates do not reflect intensive administrative and clinical services provided in the initial stages of treatment. Payer s Signature: Final Payment Credit Card Info: cash debit card VISA MC AMEX cheque wire transfer Credit Card #: Expiry Date (mm/yyyy) Security/CCV code Name on card (please print) Payer s Signature: Date: THIS DOCUMENT MUST BE COMPLETED AND FAXED 24 HOURS PRIOR TO ADMISSION. PLEASE FAX COMPLETED FORM TO ALL CORRESPONDENCE WILL REMAIN CONFIDENTIAL. 4

5 AGREEMENT OF RESPONSIBILITY FOR MEDICAL DETOX COSTS I,, agree to pay Sunshine Coast Health Centre (2005) Ltd. for the full cost ($650 per night) of time spent in the detox unit at Sunshine Coast Health Centre for : (name of client) Detox unit charges will be billed once client has been approved for release from the detox unit by medical staff. These charges are in addition to the costs of Residential Treatment. If medical staff recommend client spend additional time in detox causing charges to exceed $3250 (5 nights in the detox unit), you will be contacted by the financial department prior to payment being processed. All fees are GST and PST exempt. Prices subject to change without prior notice. Final Payment Credit Card Info: Credit Card Issuer: VISA MC AMEX Credit Card #: Expiry Date (mm/yyyy) Security/CCV code Name on card: (please print) Signature of Cardholder: Date: THIS DOCUMENT MUST BE COMPLETED AND FAXED 24 HOURS PRIOR TO ADMISSION. PLEASE FAX COMPLETED FORM TO ALL CORRESPONDENCE WILL REMAIN CONFIDENTIAL. 5

6 AGREEMENT OF RESPONSIBILITY FOR CLIENT PERSONAL EXPENSES The client agrees to cover all personal expenses. OR I, hereby authorize Sunshine Coast Health Centre (2005) Ltd. to charge for personal expenses* incurred by during treatment at Sunshine Coast Health Centre. Funds will be charged to my credit card along with a 5% service charge to cover these cash advances, providing the credit card has sufficient credit. In the event that the card issuer declines any credit card charges associated with the above expenses, I hereby agree to immediately reimburse Sunshine Coast Health Centre for said expenses, upon demand. These funds are limited to: $ Credit Card Issuer: VISA M/C AMEX Client s personal card 3rd Party credit card Name on Card: Credit Card #: Expiry Date (mm/yyyy) CCV code Address of Cardholder: Signature of Cardholder: Date Signed: The person in whose name the card is issued must complete the credit card information. If the card belongs to someone other than the client please indicate a maximum spending limit (see above). If the client does not have access to a credit card for additional expenses please detail what other arrangements will be made to cover these charges. Cheque Total available $ Cash Total available $ Name of Payee (please print) Payee Signature Date * Note: Personal expenses include special food items, tobacco, toiletries, grooming services, clothing etc. 6

7 COMPREHENSIVE FEE SCHEDULE BASIC SERVICE RATES Duration Semi-Private Semi-Private Daily Rate ADDICTION PROGRAM Private Private Daily Rate 30 day $15,960 $532 $20,760 $ day $21,420 $510 $28,140 $ day $29,700 $495 $39,300 $ day $39,600 $440 $54,000 $600 DETOX ONLY PROGRAM 7 days $6,580 $940 N/A N/A FAMILY & COUPLES PROGRAM (lodging not included) Family Program Couples Program 1 Free Free ALUMNI PROGRAM 2 14 day $5,530 $395 $7,770 $ day $11,850 $395 $16,650 $ day $23,700 $395 $33,300 $555 SOBER LIVING 3 14 day $1,708 $122 One month $2,800 $91 TRAUMA PROGRAM 30 day $22,170 $739 $26,970 $ day $27,680 $659 $34,400 $ day $35,760 $596 $45,360 $ day $49,410 $549 $63,810 $709 All Fees are GST and PST exempt. Most fees can be claimed with Revenue Canada see your accountant for advice on your particular situation. Prices subject to change without prior notice. 1) Couples Program participants must first complete the Family Program. Both events are run on consecutive days. Please note that the Couples Program is not a residential program for couples; Sunshine Coast Health Center is strictly an all-male residential facility. 2) Minimum stay in the Alumni Program is 14 days. Clients in the Alumni Program must have previously attended our program. A surcharge of $150 will be charged for each night of required detox care. 3) Sober Living available only to clients who have completed the Addiction or Trauma Programs. Continued on next page 7

8 Comprehensive Fee Schedule p.2 A non-refundable deposit of $1000 is required to hold a bed in the event that there is a wait list and will be applied towards the cost of treatment upon admission. The Detox Only Program includes travel assistance (see below for details), medical detoxification, routine nursing consultations, the Family & Couples Program and psychoeducation group. The Addiction Program includes all goods and services provided in the Detox Only Program as well as psychiatric assessment, counselling (group and individual), Online Support Program, wellness therapies (massage therapy, ozone therapy), arts and craft materials, and assigned reading materials. The Alumni Program includes all goods and services provided in the Addiction Program but does not include travel assistance in Vancouver or Comox nor does it include medical detoxification (available for an additional $200 per night). Alumni Program participants must first complete the Addiction or Trauma Program. The Trauma Program includes all goods and services provided in the Addiction Program and the Detox Only Program as well as enhanced psychiatric services, trauma counselling and complementary trauma therapies (EMDR, neurofeedback, hypnotherapy and active meditation, therapeutic exercise and therapeutic recreation). All programs include pick up/return to the Powell River airport or ferry terminal upon arrival/discharge, accommodation, meals, scheduled recreational activities, use of the business centre, use of the indoor pool and fitness centre, free laundry soap and use of laundry facilities. Programs do not include travel expenses to and from a client's place of residence to the Powell River airport or ferry terminal, dental work, prescription drugs, or personal items such as toothpaste, shaving cream, deodorant, etc. Travel Assistance (not included in the Alumni Program fee) To facilitate Addiction Program, Detox Only Program, or Trauma Program clients arriving at Vancouver International Airport or Comox Valley Airport, Sunshine Coast Health Center offers free travel assistance. Clients need not worry about luggage and shuttling between terminals, a staff member will be there to ensure your trip is hassle-free. Parking Please note that there is limited parking available at the Sunshine Coast Health Center. Clients who drive to our campus and park their vehicles will be subject to a daily rate of $5. METHOD OF PAYMENT Sunshine Coast Health Center accepts cheque or money order issued by a Canadian bank, wire transfer, Visa, Mastercard and American Express. For further info, please feel free to contact Admissions toll free PROGRAM CHANGE AND EXTENSION POLICY Clients wishing to extend their stay from one program duration to another may do so without penalty. For example, a client who has originally enrolled in the 30-day Addiction Program may extend to the 42-day Addiction Program by paying the difference in cost. No penalty will be assessed for choosing to start their treatment in a program of shorter duration. Similarly, clients wishing to change program may do so without penalty. For example, a client who has originally enrolled in the Detox Only Program may change to the 30-day Addiction Program by paying the difference in cost. Again, no penalty will be assessed for clients choosing to start their treatment in the Detox Only Program. Continued on next page 8

9 Comprehensive Fee Schedule p.3 REFUND POLICY Refunds are calculated by the number of unattended days multiplied by the daily rate of that program. An admin charge of $2000 will be charged on all refunds where the length of stay is less than 30 days. The admin charge will be waived for clients staying longer than 30 days if 7 days notice is provided. Day 1 and the last day of a client's stay are based upon the calendar day the client arrives and departs, regardless of the time of day. For example, a client who leaves at day 24 of the 30-day program will be refunded 6 days x $532 per day for a semiprivate room less the admin charge of $2000 for a total refund of $1,192. A client who provides notice and leaves at day 36 of a 42-day program will be refunded 6 days x $510 per day for a semi-private room for a total refund of $3,060. If a client arrives on campus at 10 pm that will be considered Day 1 of his treatment. If a client departs at 5 am that will be considered his final day of treatment. SESSIONAL FEE SCHEDULE Chiropractic $45 30 Minutes 60 Minutes Hypnotherapy $140 Massage Therapy $55 $100 Neurofeedback $80 Nutrition Consulting $80 $140 Nutritionist $80 $140 Ozone Therapy $70 Personal Training $50 Physiotherapy $60 Note: Sessional fees will be billed for those requesting additional sessions beyond those already included in programs. Please visit the Men's Daily Schedule at for details. WHY IS TREATMENT AT SUNSHINE COAST MORE EXPENSIVE THAN OTHER FACILITIES? 1. Not all addiction programs are equal in terms of programming, staff and amenities. At Sunshine Coast we are committed to providing the very best to our clients in all three of these areas. 2. At Sunshine Coast, you will receive highly varied and one-on-one programming tailored to your specific needs. Most treatment centres offer the exact same program to everyone and will not make alterations for any reason. 3. The staff providing your care are highly credentialed and experienced beyond what you will receive at other facilities. 4. Many services and amenities you receive at Sunshine Coast are offered at no extra charge. At other facilities, these same services and amenities will cost extra or are not offered. 9

10 PRE-ADMISSION CHECKLIST THINGS TO BRING Provincial health care card Drivers licence (if Canadian resident) or passport (if nonresident of Canada) for boarding flights. Travel insurance for coverage of emergency medical services while in British Columbia. Coverage should be sufficient for the entire length of stay in BC and although recommended for all clients, is particularly recommended for non-residents of Canada, and medically uninsured Canadians.* Toiletries (toothbrush, shampoo, shaving cream, etc.) Sleepwear (slippers, t-shirt and shorts or pajamas) Comfortable clothing sufficient for 7 days Weather-appropriate clothing and recreation wear, i.e. rain wear and a good pair of hiking boots or outdoor shoes Fitness wear (t-shirts, shorts, track pants, running shoes) for use in the fitness centre Swimwear (not cut-offs) and beach towel Musical instruments for leisure time (limited selection available onsite) Money for incidentals (will be kept in safe) If you smoke, bring cigarettes as tobacco products are not sold on the premises * Travel insurance does not cover expenses associated with non-emergency situations such as medical appointments or medications of any kind. THINGS NOT TO BRING Clothing suggestive of alcohol or drug use (including names of bars or taverns), or clothing that promotes sexism, racism or homophobia Drug paraphernalia Cameras or video equipment Heating pad or electric blankets Weapons, including pocket knives Valuable jewelry or expensive clothing Pornography Mouthwash or other toiletries containing alcohol Over-the-counter medications and herbal remedies** Nutritional supplements** NOTE: Items in this category will be confiscated and returned at time of discharge. Mood-altering drugs or medication regarded as counter-therapeutic by our medical staff will not be returned. ** If you are not sure about a drug, supplement, beverage, or food item please check with Admissions prior to your admission date. Please note that Sunshine Coast provides complimentary nutritional supplements. MISCELLANEOUS Personal Electronic Devices: Personal communication (cellphones, Blackberry's, etc.), audio (ipods, MP3 players, etc.), and computing devices (notebooks, laptops)*** are permitted provided that usage rules are observed at all times. Cameras or video equipment are not permitted. *** Wireless internet is usually available but download speeds can be affected by bandwidth-intensive activities. Internet service is intended for communication purposes, not entertainment. Incidental Items: Phone cards and postage are available through Reception. Safekeeping for money, passports and airline tickets is available. We are not responsible for lost or stolen jewelry, cameras or other valuables. Laundry Facilities: A washing machine, dryer, iron, ironing board and laundry soap are available at no charge. Visitors: Family members are welcome to visit Sundays and holidays from 12:00 to 5:00 PM. Telephone: Residents can be reached on the client phone. Clients are responsible for providing the number of the client phone to family and friends. Luggage: Please note that Pacific Coastal Airlines charges $0.65/lb. for luggage weight exceeding 50 lbs. Mail: The mailing address for letters and packages is: Client s Name c/o Sunshine Coast Health Center, 2174 Fleury Road, Powell River, BC, V8A 0H8, Canada. 10