THREE VOICES OF HEALING SOCIETY 1001 Capilo Way Invermere, BC Mailing Address Box 325 Invermere, BC V0A 1K0 Telephone: 778-526-2501 Facsimile: 778-526-2505 Toll Free 855-526-2502 Electronic mail: admin@healingisajourney.com Website: www.healingisajourney.com AFTERCARE PROGRAM General Information The primary Mission of Three Voices of Healing Society s Wellness Centre is to promote and encourage First Nations people and other Aboriginals to live Holistic lives. The Wellness Centre s philosophy and treatment approach is based on Personal Development programs dealing with the disease concept of alcoholism and drug addiction, and the personal history that contributes to the abuse of alcohol and other drugs. This philosophy is maintained through Holistic and Cultural concepts. The Wellness Centre is an accredited non-medical residential treatment facility with 12 beds for adult men who are currently experiencing substance abuse problems and 20 beds for male clients continuing treatment with our Aftercare program. The program is designed to assist these individuals in staying free from their chemical dependency and discover/re-discover healthy, responsible living. We offer a 91 day aftercare program to provide further assistance in re-establishing stability in their own community. Please make sure your client will have Steel Toed Boots for the program. The Program Offers: 1x1 Counselling Conflict Resolution Mentorship Program Highschool Upgrading Recreational Activities Bridge to Trades (NVIT) Traditional/Cultural Activities Personal Development Qualifications: First Nations/ Inuit Adult Men Ages 19 and over Committed to full length of program (91 day minimum) Have a need or desire to improve lifestyle Participate in all aspects of the program Focus on self (self-awareness) Complete Referral Application Complete Medical Examination and T.B. Test Results The Wellness Centre is located on the Shuswap Band Reserve, Ten kilometers south of Radium Hot Springs and Two Kilometers north of Invermere. The location has easy accessibility to the Hospital, Recreational Center, Churches, Shopping facilities, and Restaurants. For your information, we have enclosed an Admission Criteria, Referral Assessment, and Referral Application Package for your department and prospective clients. If you require further information, please feel free to give us a call or write Three Voices of Healing Society at the above address; email us at admin@healingisajourney.com or visit our website www.healingisajourney.com. Thank you for your interest in our program. We look forward to working with you in our combined efforts to promote a healing journey within our Aboriginal communities. 1
IMPORTANT To: ALL REFERRAL WORKERS & APPLICANTS From: TVOHS Executive Director RE: Mandatory T.B. Testing The Wellness Centre would like to take this opportunity to inform all referral workers that Tuberculosis tests results are mandated by Health Canada and that a copy of the results must be included with the application to any NNADAP Treatment Centre. Please note that a copy of a Negative T.B. test result taken within the past 12 months is acceptable. Thank you for your attention to this matter. If you have any further questions, please feel free to contact us at: 778-526-2501 TVOH ADMISSION CRITERIA Please read carefully 1. Client has completed a recognized treatment program. 2. Client expresses a need and desire to change his/her present life-style. 3. Clients who receive a comfort allowance while attending TVOH wellness centre must have the cheque made payable to Three Voices of Healing Society as the funds will be dispersed to the client. 4. Client should have a minimum of two months abstinent from alcohol/drugs prior to admission. 5. Client should have no outside interference during the 91 Day aftercare program (ie. court appearances, doctor, physiotherapist or dentist appointments etc.) 6. Travel arrangements, comfort allowance, and any additional expenses must be pre-arranged with the clients Referral Worker and/or Social Worker prior to client s entry for aftercare. All other necessary payments such as rent, utilities or other necessary payments should also be arranged. 7. Client is physically able to participate in an ongoing counseling experience. 8. If client has a history as a sex offender (known or charged as such), he will let it be known to the centre. 9. Client does not have any legal issues and/or court cases during aftercare. Please note that special exemptions can be made for certain criteria. ADDITIONAL MEDICAL CRITERIA Note: All medical exams and referral packages expire after six months and Tuberculosis tests expire after one year. Prior treatment medical exam and TB Test is acceptable if within 6 months. 1. Client does not require acute hospital care or Detox facilities. 2. If the client has a dual diagnosis, the referral worker is required to obtain and submit all documentation including those from a doctor, that the client is stable and capable to enter our aftercare program. It is mandatory by the Provincial A&D Services that the Referral Worker shall provide the Doctor(s) with information about the centre to ensure they are knowledgeable about our program prior to presenting their recommendation. 3. Attending physician must be the prescribing physician. (It is best that the client sees his regular family physician rather than a physician at a Walk-in Clinic.) 2
Three Voices of Healing Society & Wellness Centre APPLICATION FOR AFTERCARE Last Name (legal): First Name: Known as (if different from above): Address: City: Postal Code: Phone #: Age: Birth date: Yr: Mo: Day Marital Status: Ancestry/Nation: Band Name: Status Number: SIN: Medical Number: How are Medical premiums paid? DIA Social Services Self Family Physician: Phone#: Social Worker (if applicable) Name(s): Address: Phone #: Next of Kin: Relationship: Address: Phone #: Emergency Contact: Relationship: Address: Phone: 3
THREE VOICES OF HEALING SOCIETY 1001 Capilo Way Invermere, BC Mailing Address Box 325 Invermere, BC V0A 1K0 PH: 778-526-2501 or FAX 778-526-2505 Toll Fee: 855-526-2502 Electronic mail: admin@healingisajourney.com Website: www.healingisajourney.com REFERRAL SOURCE: (Name of Organization Referral) ADDRESS: Postal Code: PHONE: FAX: ORGANIZATION E-MAIL: REFERRAL WORKER: (Name of counsellor filling out this package with client) TITLE We need a 24 hour contact number in case of emergency for arranging transportation, as well as informing of evacuation or other crisis (if the need arises). Name: Phone: APPLICATION CHECKLIST (Please Check) Medical Examination Complete Referral Package Tuberculosis Test Results Consent Signed 4
Three Voices of Healing Society & Wellness Centre REFERRAL ASSESSMENT Please answer ALL of the following questions. Abilities 1. Does the client have any physical limitations that would prevent them from doing daily living Chores, recreational or cultural activities? Yes No 2. Is client free of all personal factors (family situations, dentist, job/school responsibilities, etc.) that could interfere with the Three Voices of Healing Wellness Program? Yes No 3. Will the client have funds for return travel costs if their program is incomplete? Yes No Client Addiction History 1. History of substance use (including current use and clean date): Substance Type Times Per Day/Week Amount Age Started Use Date Of Last Use Alcohol: (Beer, Wine, Whiskey, Vodka, Coolers, Lysol, etc) Hallucinogens: (Marijuana, Mushrooms, Hash, etc) Narcotics: (Cocaine, Codeine, Opium, Meth, Heroin, Crack, Speed, etc) Prescribed: (Tylenol-3, Anti-depressants, Valium, Morphine, Seconal, ect.) Inhalants: (Gas, Glue, Aerosols, Spray Paint, White-out, etc.) Tobacco: (Cigarettes, Cigars, Pipe, Chewing Tobacco, etc.) Other: (Coffee, Pop, Gambling, Shopping, Sex, etc.) 5
Three Voices of Healing Society & Wellness Centre Client Addiction History Continued 1. Do you have Process Addictions? (i.e.: gambling, shopping, sex, food) Yes No 2. Are you currently on any medications? Yes No a) For what purpose? b) Name of medication c) Amount prescribed Please attach a separate sheet if additional room is required 1. Treatment history - Please complete table below. If you left a program before completion please list reason. PRESENTING PROBLEMS NAME & ADDRESS OF TREATMENT FACILITY DATES OF ATTENDANCE COMPLETED Yes/No Alcohol/Drug (Treatment, Detox, etc.) Emotional Problems (Anger, Depression, etc.) Family Problems (Family Counseling etc.) Process Addictions (Gambling, Shopping, etc.) Suicidal Ideation /Attempts (Please attach relevant reports) 6
Three Voices of Healing Society & Wellness Centre Form for Client, Counselor, SA Worker, Coordinator, NNADAP Worker, etc. This form must be filled out before an acceptance letter can be sent. Before we can accept your client into our Aftercare program, we like to have confirmation that the following requirements have been secured before his arrival. If the client is confirming this information, please have the client initial. If the client s needs are being handled by the referral worker, please have the referral worker initial. This serves to confirm that the client will have rent & utilities in order, comfort allowance is provided/allotted, and all personal items listed below are provided/brought for them: (Please Initial) I confirm that my (client s) rent and utilities are paid/will be paid for the duration of the Aftercare program. I confirm that my (client s) comfort allowance will be forwarded to the centre in a timely manner, to be dispersed to my client. I confirm that all personal items and hygienic needs will be provided for my (client) before arriving to the centre (ie: indoor running shoes, swimsuit/swim shorts, calling card, toothbrush, shampoo/conditioner, and adequate clothing for 91 days). Signature of Client, Counsellor, or S.A.Worker as applicable: 7
Date: Personal Identification Information 1. Family Type Couple Spouse & Children Single Parent Living w/parents Living w/extended Family Living w/friends Living Alone 2. Number of Children At home In-care Apprehended 3. Do you have secure child care for the 91 Day aftercare program? Yes No 4. Have you been raised by your natural parents? Yes No 5. Have you ever been in foster care? Yes No When? For how long? 6. Do you speak your traditional language in your home? Yes No Primary Language spoken: 7. Native culture and spirituality practiced? Yes No 8. Are you allergic to or have had a reaction to any medication? Yes No If so, What? Are you allergic to any Foods? Yes No If so, What? Has your Doctor prescribed an epi pen for any of these allergies Yes No 9. Have you attempted, thought about, or had feelings about suicide? Yes No Please Specify: How recent? 10. Any eating disorders (i.e. anorexia, bulimia, overeating, etc.)? Yes No If yes, please identify: 11. Are you on a special diet? Yes No If yes, please explain: 8
12. Did you attend a Residential School? Yes No If yes, how many years? I. Personal Identification Information (Continued) 1. Employment (Prior to treatment) Usual Occupation: Full Time Part Time Full Time Seasonal Part Time Seasonal Self Employed Unemployed Student Homemaker Retired Disabled 2. Income Source 3. Legal Status- Please fill out all sections, even if the client has no current legal status. A) Is Client a sex offender? Yes No B) Current Legal Status Yes No C) Does the client have any current legal orders in place? Yes No If Yes please indicate by circling; Probation Parole Day-Parole Bail Own recognizance Electronic monitoring Other If the client has any current legal orders in place please list type of order (ie Spousal Assault, DWI, Theft, Breach, etc) D) Reason for conviction(s) - Please be specific - (i.e. Assault, Drugs, Sex Offence, etc.) Date of release Length of supervision E) Previous Convictions; Yes No If yes list type of conviction and dates: F) Were any of the above charges Alcohol/Drug related? Yes No G) Does the Client have any pending Charges/Court Dates Yes No Pending charges Court Date All court dates for pending charges must be dealt with before an intake date is scheduled. Conditions of probation, parole or electronic monitoring must accompany this application. Parole/Probation Officer: Phone: Address: City If probation and/parole have conditions to the client being in the program, the Probation Officer will be notified by TVOHS if the client completes the program. 9
Education and Employment Summary 1. Did you graduate from high school? Yes No If no, what was the last grade completed? 2. Will you require support with reading and/or writing? Yes No 3. Did you attend any Post Secondary institution? Yes No What other education, training or courses have you completed? 4. Do you have a disability that is permanent? Yes No 5. Have you ever been told that you have a learning disability? Yes No ( ex. Brain injury, ADD)? 6. What is your desired field of employment? Trades and labor, Health care, Hospitality or Other If other please list 7. Do you have any computer skills? Yes No 8. Do you have any tickets or certificates? Yes No 9. What do you see as a barrier for finding employment? 10. What are your educational goals? 11. What do you hope to get out of our Aftercare Program? Employment History Employer and Position you worked Start Date and End Date Reason you left 10
Three Voices of Healing Society & Wellness Centre Consent for Treatment I agree to enter the Three Voices of Healing Wellness Centre for the purpose of aftercare treatment and healing. I understand that if I require emergency medical attention, I will be transported to an appropriate facility. I also agree to be involved in D & A counseling upon my completing the Three Voices of Healing Aftercare Program. I fully understand the above points and the Three Voices of Wellness Centre guidelines; therefore I consent to undergo the aftercare program at the Three Voices of Healing Wellness Centre. I fully understand that any false information given may be cause for dismissal from the program. Date: Signature: Consent for the Release of Confidential Information I hereby give my consent to Three Voices of Wellness Centre to use information in my client file for the purpose of data collection for the outcome study and program development. I hereby give my consent to Three Voices of Wellness Centre to contact: Name Title: (Example: referral worker, probation officer, physician, psychologist etc) Address: Phone: (Info of contact person named above) Information to be released shall be limited to (Example: progress during treatment, discharge summary, etc.) Date: Client Signature: Witness Signature: Name (please print): Location: 11