Treatment Program Referral Package. The Salvation Army s Intensive Eight Week Non-Residential Treatment Program

Transcription

1 Treatment Program Referral Package The Salvation Army s Intensive Eight Week Non-Residential Treatment Program The Salvation Army Williams Lake Corp 267 Borland Street Williams Lake, B.C. V2G 1R Wladdictions@shaw.ca Attention: Treatment Program ~ 1 ~

2 The Salvation Army s Intensive Eight Week Treatment Program Schedule (Please indicate which Program dates you wish to attend) Program Start Date is _and Program end date is_ Program Start Date Program End Date Tuesday, August 7, Friday, September 28, 2012 Tuesday, October 9, Friday, November 30, 2012 Two Week Refresher Program Monday, December 3, 2012 Friday, December 14, 2012 Monday, January 7, Thursday, February 28, 2013 Monday, March 11, 2013 Friday, May 3, 2013 Monday, May 13, Friday, July 5, 2013 Monday, July 15, Friday, September 6, 2013 Monday, September 16, 2013 Friday, November 8, Week Refresher Program Monday, November 18, 2013 Friday, November 29, 2013 Signature Date ~ 2 ~

3 Greetings The Salvation Army s Intensive Eight Week Non-Residential Treatment Program is designed to provide you with the insight, understanding and the tools needed to deal effectively with the issues related to alcohol/drug use, misuse, abuse and addiction. Holistic in nature, this program takes a bio-psych-social-spiritual approach with the goal towards re-establishing balance to all life areas. There are numerous issues that go hand in hand with living an addicted lifestyle. In learning to live a healthier, happier, more fulfilling and productive lifestyle we ask that you be fully committed to achieving sobriety and be ready to make a firm commitment to attend this program daily, as scheduled, and to fully participate in all activities, exercises and group processes as assigned. Please ensure that you have given yourself sufficient time to fully detoxify from the effects of what you have been using (at least 7-10 days). Each of you will be provided with a schedule of activities on the first day of the program. These elective/volunteer/spiritual development activities will be negotiated with you during the first week of the program. Note: Beginning January, 2013 there will be a fee for this Program. The fee for this two month (40 day) Treatment Program will be $30.00 per diem, for a total of $1, This fee includes: breakfast, lunch, Program materials as well as counselling services. Please ensure that funding is in place before the start date of the program. If you are unable to access funding to cover the costs associated with this program the Salvation Army may be able to assist you. Please contact the Salvation Army to discuss. The two week refresher programs will be offered, free of charge, to any person who has previously completed this Treatment Program. Please contact the Salvation Army at least two weeks prior to their start date. It is our hope that you will take full advantage of all that this program has to offer. We feel confident that, with your sincere desire and motivation to make positive lifestyle changes in your life, and by fully participating in and using the tools provided through this program, your experience here will prove to be enjoyable, beneficial and of significant value to you and, ultimately, to all group participants. Please answer all questions on this Treatment Program Referral Form. Read, sign and date the attached Code Of Conduct and complete, sign and date the Consent Form To Release And Share Information. This completed referral package can be dropped off, mailed or faxed to the address (fax number) listed on the front page of this referral application. Once received, your Treatment Referral Package will be reviewed and you will then be contacted by our Addictions Counsellor. Should you have any questions and/or issues that require immediate attention please call Steve at or at: Wladdictions@shaw.ca Thank you! ~ 3 ~

4 Surname (legal): First Name(s): Address: City: Province: Postal Code: Telephone #: (Area Code) Birth date: Year Month Day Gender: Male Female Aboriginal Ancestry Band Member Aboriginal Information On Reserve (Band Name, Inuit, Métis, Aboriginal Community) Status Number S.I.N. Care Card Number How are medical insurance premiums paid? D.I.A. M.H.R. Self How is the treatment paid? FNIHB M.H.R. Self Band Employer Other (Please ensure that payment arrangements have been completed prior to the Program start date) Emergency Contact: Emergency contact Emergency Contacts Relationship to Client: Education Level: _ Other Community/Agency Involvement (List): Medical Information: Telephone Number: (Area Code) Physicians Name: Clinic: Telephone Number: ~ 4 ~

5 Please identify any existing medical conditions: (Allergies, Seizures, Heart Condition, Asthma, etc.) EMPLOYMENT STATUS Occupation: Full Time Part Time Full Time Seasonal Part Time Seasonal Unemployed Retired Student Homemaker Not in Labor Force (due to disability) Source of Income? CURRENT MARITAL and FAMILY STATUS Single Common-Law Divorced Married Separated Widowed Extended Family Living Alone Single Parent Living with friends Number of dependent (0 18 years of age) children: Living with family Living with Spouse & Children Ages of children 0 to 4 5 to 9 10 to to Does client have secure Child Care for the intensive eight week treatment program? 2. Has client been mandated to treatment by MCF? If yes client understands that the Salvation Army is not obligated to keep them if they are not willing to adhere to Code Of Conduct of the program and fully participate in the program 3. Is a Social Worker currently involved with the Family? If yes please provide details of involvement. Have you ever attended Treatment before? PRIOR TREATMENT AND/OR COUNSELLING List all previous Treatment Centre s attended and/or counseling received for Alcohol &/or Drugs, Emotional Problems (anger, depression, Suicide), Family Problems (marriage/relationship), Process Addictions (gambling, shopping), Legal. Treatment Centre/ Counselor/Institution Name Location Date (M/D/Yr) Start to End Issues Worked On Completed ~ 5 ~

6 Have you ever experienced the following as a result of your alcohol/drug use? Car Accident Arrest Personal Injury Roadside Suspension Criminal Charges Incarceration Admission to Hospital DUI If you indicated yes to any of the above please discuss. 1. Are you committed to complete an intensive, structured treatment process? 2. Are you willing to fully participate in all intensive group counseling activities? 3. Do you acknowledge the need to change your life situation? 4. Do you believe addiction is a serious problem to your well-being? 5. Do you believe that sobriety is needed in order for you to change? 6. Are you able and willing to adhere to the Code Of Conduct of the Salvation Army s Intensive Day Treatment Program? (see last page) If, have you read and do you understood the Salvation Army s Code of Conduct? Date: 7. Any major problems in your life situation relating to alcohol/drug abuse in the following areas? Physical Health Legal Housing Family/Friends Employment Leisure Time ~ 6 ~

7 Financial Mental Health If you have answered yes to any of the above, please explain 8. Will you be free of all factors that would interfere with the Salvation Army s Treatment Program? (Family, work, school, medical, legal, childcare, court appearance etc) 9. Do you have discharge plans: for basic needs (housing, food, etc.) for continued AA or NA or other support group attendance. to continue in cultural/spiritual activities at local community. for Outpatient / Aftercare counseling with you as A/D counsellor. 10. Do you have specific needs to be addressed in treatment? If yes please explain: Spiritual Mental Emotional Physical PHYSICAL HISTORY 1. Do you have any physical limitations that would prevent you from participating in: Daily Fitness Class, Volunteer Activities/Chores, Recreational or Other Activities? 2. Do you have any special needs that Salvation Army staff should be aware of while you are attending treatment? 3. If you have answered yes to question #2 please explain CURRENT DIAGSTIC STATUS Check all applicable boxes: Provide Brief explanation if applicable: ~ 7 ~

8 Trauma (PTSD) Depression Anxiety/Panic Disorder Any type of mental disorder Brain Injury ADD/ADHD Anger/Acting Out Family Trauma (Child apprehension, custody problems, lateral violence, marriage problems/breakdown, etc) Grief and/or Loss (please explain type of loss with who what, when) FAS/FAE (If FAS/FAE please provide results along with the date of testing) Suicide Ideation Suicide Attempts Do you agree to notify Salvation Army staff should you experience suicidal ideations or have thoughts of harming yourself? Yes No EMPLOYMENT STATUS Occupation: Full Time Part Time Full Time Seasonal Part Time Seasonal Unemployed Retired Student Homemaker Not in Labor Force (due to disability) Source of Income? Alcohol/Drug Use History 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 Age of first use Frequency/How often used: Daily/wkly/mthly Date of last use Alcohol (eg. beer, wine, hard liquor) Cannabis (e.g. pot, hash) ~ 8 ~

9 Cocaine (e.g. crack, coke) Hallucinogen (e.g. acid, mushrooms, PCP, ketamine) Barbiturate (e.g. bennies, yellow jackets) Amphetamine (crystal meth, ecstasy, speed) Heroin (eg. china white, crank) Opiate (eg. morphine, codeine, opium) Inhalant (e.g. glue, hairspray, gasoline) Illicit Methadone Benzodiazepine (eg, sleeping pills, tranquilizers) Over the Counter Drugs (e.g. cough syrup) Other Prescription Drugs (e.g. T3 s, Valium) Tobacco Other Michigan Alcohol Screening Test (MAST) # The following questions are about your alcohol use during the past 12 months Circle Your Response 1. Do you feel that you are a normal drinker? 2. Do friends or relatives think you are a normal drinker? 3. Have you attended a meeting of Alcoholics Anonymous (AA)? (5) 4. Have you lost friends or girlfriends/boyfriends because of your drinking? (2) 5. Have you gotten into trouble at work because of your drinking? (2) 6. Have you neglected your obligations, your family or your work for two or more days in a row because you were (2) drinking? 7. Have you had delirium tremens (DT s), severe shaking, heard voices or seen things that were not there after heavy drinking? (2) 8. Have you gone to anyone for help about your drinking? (5) 9. Have you been in a hospital because of drinking? (5) 10. Have you received a 24-hour roadside suspension or have you been charged for impaired driving? (2) (2) (2) Total Score ~ 9 ~

10 Total scores may range from 0 to 29. Scores of 6 or greater are considered to reflect serious problems with alcohol. DRUG ABUSE SCREENING TEST # The following questions concern information Circle Your Response about your potential involvement with drugs not including alcoholic beverages during the past 12 months 1. Have you used drugs other than those required for medical reasons? 2. Have you abused prescription drugs? 3. Do you abuse more than one drug at a time? 4. Can you get through the week without using drugs? 5. Are you always able to stop using drugs when you want to? 6. Have you had blackouts or flashbacks as a result of drug use? 7. Do you ever feel bad or guilty about your drug use? 8. Does you spouse (or parents) ever complain about your involvement with drugs? 9. Has drug abuse created problems between you and your spouse or your parents? 10. Have you lost friends because of your use of drugs? 11. Have you neglected your family because of your use of drugs? 12. Have you been in trouble at work because of drug abuse? 13. Have you lost a job because of drug use? 14. Have you gotten into fights when under the influence of drugs? 15. Have you engaged in illegal activities in order to obtain drugs? 16. Have you been arrested for possession of illegal drugs? 17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 18. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc)? ~ 10 ~ 19. Have you gone to anyone for help for drug problem?

11 20. Have you been involved in a treatment program specifically related to drug use? Total Score Drug Misuse Screening Test Problem Severity Score 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 LEGAL STATUS: A. Current Legal Status is T APPLICABLE B. Do you have any current charges/ Court dates in place? C. If yes to B, you must specify type of legal order in place (I.e. Spousal Assault, DWI, Theft, Breach, Failure to Appear, Undertaking, Restraining Order, etc.) D. Were the charges Alcohol/Drug related? E. Are you under a curfew? Name of Probation Officer: Telephone No: **IMPORTANT TE: A COPY OF THE PROBATION ORDER MUST BE INCLUDED WITH THE APPLICATION FOR TREATMENT BEFORE THE APPLICATION CAN BE ASSESSED. F. Do you have any previous Convictions/Charges? G. If you answered yes to G. please list all previous convictions/charges and dates ~ 11 ~

12 Problem Statement (Please provide a written description of how your alcohol/drug abuse has negatively impacted your life and tell us what has motivated you to seek treatment at this time) ~ 12 ~

13 Code Of Conduct The Salvation Army s Intensive Eight Week Non-Residential Treatment Program has been designed to provide individuals with a balanced, holistic approach to dealing with substance abuse and chemical dependency issues. To ensure that this mission is successful we have established a Code Of Conduct for all individuals participating in this program. The Salvation Army expects program participants to respect this program and other program participants by adhering to the following basic program-wide rules. Failure to follow these guidelines may result in you being discharged from this program prior to its completion. I understand that while participating in the Salvation Army s Intensive Non-Residential Recovery Program I am expected to: 1. Maintain confidentiality about other participants during treatment. What s said in the group stays in the group. 2. Be on time for and attend all group sessions/activities, unless otherwise excused. 3. Attend all scheduled volunteer, spiritual development (including Chapel Service) and fitness activities as arranged. 4. If you will be late or are not able to attend the program for any reason you must notify your counselor immediately by telephone. 5. Actively participate in all group activities. 6. Adhere to the no smoking policy in our building. 7. Have your cell phone turned off during group sessions. 8. Other reasons I may be discharged from the Salvation Army s Treatment Program include: a. Drug or alcohol use on the Salvation Army premises. b. Possession of alcohol, drugs or paraphernalia on Salvation Army premises. c. Missing a group without providing a reasonable excuse or doctor s note. d. Violent/Aggressive behavior or Verbal Threats made toward other participants or staff members. e. Exhibiting behavior that is disruptive to the group. f. Lack of progress in the program. Client s Signature Date By signing my name, I acknowledge that I have read, understand and agree to comply with the Salvation Army s Code Of Conduct as set out above. ~ 13 ~

14 CONSENT FORM TO RELEASE AND SHARE INFORMATION Client Name: _ Phone: I authorize the following agencies to release and share information about me/my file(s) with the Salvation Army in order to facilitate my recovery through my involvement in their eight week Alcohol and Drug Day Program. This consent will remain in effect for 2 years from the date signed unless revoked by me in writing. Please initial those which apply Ministry of Social Development Ministry For Children and Family Development Williams Lake Employment Services Personal Physician/Medical Personnel CCATEC/Metis Association/Indian Band National Native Alcohol and Drug Program Cariboo Friendship Society Williams Lake Community Corrections/Probation Victims Services CMHA/Williams Lake Mental Health Interior Health/Cariboo Memorial Hospital RCMP Employer (Tolko) Family Members Volunteer Organization Other: Client Signature Date ~ 14 ~

15 Intensive Eight Week Non-Residential Treatment Program Schedule Monday Tuesday Wednesday Thursday Friday 9:00-9:20 Optional Breakfast Optional Breakfast Optional Breakfast Optional Breakfast Optional Breakfast 9:20-9:50 Fitness/Aerobics Fitness/Aerobics Fitness/Aerobics Fitness/Aerobics Fitness/Aerobics 10:00-12:00 12:00-1:00 Lunch Lunch Lunch Lunch Lunch 1:00-2:00 Elective Volunteering (Paying It Forward) Elective Spiritual Dev. Elective Chapel Elective Volunteering (Paying It Forward) Elective Volunteering (Paying It Forward) 2:00-2:15 BREAK BREAK BREAK BREAK BREAK 2:15-3:30 TE: Attendance to Fitness classes is an integral component to the Treatment Program and is therefore mandatory Tuesday s Spiritual Development Class is held at 1:15PM and attendance is mandatory (Alternatives to this activity can be negotiated) Wednesday s Chapel Service is held at 1:15PM and attendance is mandatory (Alternatives to this activity can be negotiated) ~ 15 ~