THREE VOICES OF HEALING SOCIETY

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 Electronic mail: admin@healingisajourney.com Website: www.healingisajourney.com 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 adults who are currently experiencing substance abuse problems. We are an all men centre. The program is designed to assist these individuals in freeing themselves from their chemical dependency and discover/re-discover healthy, responsible living. We offer six week residential treatment programs which are followed by an individualized aftercare program appropriate to the individual, to provide further assistance in re-establishing stability in their own community. The Program Offers: Qualifications: 1x1 Counselling First Nations Adult Ages 19 and over Group Counselling Committed to full length of program Psychological Services Have a need or desire to improve lifestyle Alcohol/Drug Education Participate in all aspects of the program Recreational Activities Focus on self (self-awareness) Physical Fitness Complete Referral Application Traditional/Cultural Activities Complete Medical Examination and T.B. Test Personal Development 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: 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 Email: admin@healingisajourney.com Website: www.healingisajourney.com 2

THREE VOICES OF HEALING SOCIETY TVOH ADMISSION CRITERIA- Please read carefully 1. Client recognizes that alcohol/drug abuse is a problem in their life. 2. Client recognizes that life conflicts (ie. impaired driving, child apprehension, etc.) are caused as a result of their alcohol/drug abuse. 3. Client expresses a need and desire to change his present life-style. 4. Clients who receive a comfort allowance while attending TVOH wellness centre must have 2 pieces of ID including one PHOTO ID. If your client does not have these they will be unable to cash their comfort allowance cheques. TVOH will no longer be able to accept any comfort allowance cheques. 5. Client should have a minimum of two weeks detoxification from alcohol/drugs prior to admission. 6. Client should have no outside interference during the six week treatment program (ie. court appearances, doctor, physiotherapist or dentist appointments etc.) 7. 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 treatment. All other necessary payments such as rent, utilities or other necessary payments should also be arranged. 8. Client is physically able to participate in an intense counseling experience. 9. If client has a history as a sex offender (known or charged as such), they will let it be known to the centre. 10. Client does not have any legal issues and/or court cases during treatment. Note: TVOH Wellness Centre will not accept referrals that come directly from a Correctional Facility. If the client is being released, they require 30 days back in their community and six sessions with a referral worker in their community who will be seeing the client Pre and Post Treatment. 11. It is a TVOH Policy that we cannot accept clients that are taking psychoactive drugs, Mood-altering medications, Opiates or Narcotics.(example: tranquilizers, methadone; Tylenol 3, Morphine, Valium, Codeine). ADDITIONAL MEDICAL CRITERIA Note: All medical exams and referral packages expire after six months and Tuberculosis tests expire after one year 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 treatment centre. 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.) RECOMMENDATIONS: IF CLIENT DOES NOT MEET THE ADMISSION CRITERIA 1. Encourage client to become involved in sober social and recreational activities. 2. Link client to a sober social network in the community. Encourage client to attend A.A., N.A. or other Support group. 3 Refer client to Detoxification Unit within a medical facility. 4. Engage client in regular individual and/or family counselling sessions. 5. Monitor and keep in touch with client. When the opportunity presents itself, you may be available to begin preparation for treatment. 6. Conduct a re-assessment of client s readiness for treatment again in three to six months. 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 Electronic mail: admin@healingisajourney.com Website: www.healingisajourney.com NAME OF CLIENT AGE CONTACT PHONE # 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

REFERRAL ASSESSMENT Please answer ALL of the following questions. Strengths 1. Does the client express a desire or willingness for change? Yes No 2. Describe what action the client has taken in preparation for the treatment program at TVOH Wellness Centre. 3. Has the client attended at least six counseling sessions in the past six months? Yes No 4. Has the client recently attended a Detoxification Unit? a) If yes, when? b) How long in Detox? c) Has client maintained sobriety since completion of Detox? Yes No 5. Has your client been willing to participate in intensive counseling? Yes No 6. Has your client been clean and sober for a minimum of 14 days? Yes No 7. Is the client willing to participate in daily Smudge and Cultural activities? Yes No Needs 8. Does the client have any specific needs to be addressed in treatment? Yes No If yes please explain. Spiritual Physical Mental Emotional Abilities 9. Does the client have any physical limitations that would prevent them from doing daily living Chores, recreational or cultural activities? Yes No 10. 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 11. Will the client have funds for return travel costs if their treatment is incomplete? Yes No 5

Please check Problem Area: Adult Trauma Anger Management Anxiety/Panic Attention-Deficit/ Hyperactivity Disorder Borderline Personality Traits Childhood Trauma Chronic Physical Pain Cognitive Deficits Dependency Disassociation Depression Eating Disorder FAS/FASD Financial Stress Grief Loss/ Unresolved Impulse Control Disorder/ Impulsivity Intimate Relationship Family Conflict Living Environment Deficiency Low Self Esteem Mania or Hypomania Medical Issues Narcissism Obsessive-compulsive issues Paranoid Ideation Parenting Peer Group Negativity Phase Of Life Problems Phobias Post Traumatic Stress Disorder Psychosis Residential School Issues Sexual Dysfunction Sexual Identity Confusion Sleep Disturbance Sociopathy Social Discomfort Somatization Spiritual Confusion Suicidal Ideation Vocational Stress Other Details/ Brief Explanation: 6

APPLICATION FOR TREATMENT Last Name (legal): First Name: Known as (if different from above): Address: City: Postal Code: Phone #: Birth date: Yr: Mo: Day Age: Gender: Male Female 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: 7

I. Form for Client, Counsellor, SA Worker, Coordinator, NNADAP Worker, etc. (If Applicable) Before we can accept your client into our treatment program, we like to have confirmation that the following requirements have been secured before his/her 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 treatment 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 six weeks). Signature of Client, Counsellor, or S.A.Worker as applicable: Date: 8

I. 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 six-week treatment program? Yes No 4. Have you been raised by your natural parents? Yes No 5. Have you ever been in foster care? When? 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 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: 12. Did you attend a Residential School Yes No If yes, how many years? 13. Did you graduate from high school? Yes No If no, what was the last grade completed? What other education, training or courses have you completed? 14. Will you require support with reading and/or writing? Yes No 9

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; 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. 10

I. Client Addiction History 1. What is the clients motivation for entering treatment? 2. Date of last alcohol and/drug use: (Minimum of two weeks prior to treatment) Chemical History 3. History of substance use (including current use): 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.) 11

2. Client Addiction History 3. Have you ever injected drugs? Yes No a) If so, what is the date of first injection use? b) If so, what is the date of last injection use? 4. Have you shared needles with other intravenous drug users? Yes No 5. Do you have Process Addictions? (i.e.: gambling, shopping, sex, food) Yes No 6. 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 7. Any alcohol and/drug problems in your family of origin? Yes No 8. Has there ever been a death in the family due to alcohol/drugs? Yes No 9. Have you suffered any of the following abuses? Please check. Physical Emotional Sexual Mental How did you react to this abuse? 1. Treatment history - If you have never attended a treatment program, Please Check If you have attended a program 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) 12

2. Client Addiction History (Continued) 2. Have you ever sought Psychiatric Care? Yes No If yes please give details 3. What were the factors that initiated applying for admission to Three Voices of Healing drug and alcohol treatment program? Please explain 3. Client Issues and Goals Identified Issues and Concerns Goals 13

Referral Worker/Counsellors Assessment 1. Is the client receiving counselling from you? Yes No If yes: 1) How many sessions in the last six months? 2) How many sessions in the last two months? If no: How was the client referred to you? 2. What issues have the client addressed prior to attending this treatment program? 3. What is the client s presenting problem (s)? 4. What is his or her insight of the problem (s)? 5. What do you believe is the Three Voices of Healing Wellness Centre s role in your clients recovery? 6. Will you continue to see the client once he/she has completed our treatment program? Yes No If no, what steps have been taken to ensure that the client is following his/her Aftercare plan? 14

Consent for Treatment I agree to enter the Three Voices of Healing Wellness Centre for the purpose of drug and/or alcohol 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 counselling upon my completing the Three Voices of Healing Treatment Program. I fully understand the above points and the Three Voices of Wellness Centre guidelines; therefore I consent to undergo alcohol and drug treatment 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: 15

Pre-Acceptance Medical Evaluation (Patient to complete this section) Client Name: Date of Birth: Medical #: Status #: Address: Client Release I hereby request and permit Dr. to release personal medical information to: Three Voices of Healing Wellness Centre 1001 Capilo Way Invermere, B.C. Mailing Address Box 325 Invermere BC V0A 1K0 PH: (778) 526-2501 or FAX (778) 526-2505 And to my Referral agency: Agency Name: Contact Name: Address: Phone: Client Signature: Date: To the Physician: Your patient is being considered for admission to Three Voices of Healing Wellness Centre, a residential Drug and Alcohol treatment facility. Our program runs for six weeks and often we are required to take a client to a local Physician and/or Emergency Department. Please attach any current test results. Please note that the applicant is responsible for any fees charged for completion of these Pre Acceptance Medical Examination forms. 16

Pre-Acceptance Medical Evaluation (Physician to complete this section) Patients Name: D.O.B. The Wellness Centre would like to take this opportunity to inform all referral workers/ Physicians 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. Are there clinical concerns or disorders for the following? If yes please explain. 1. Functional Inquiry: Diabetes: Yes No Eyes, ears nose throat: Yes No Muscular skeletal: Yes No Respiratory: Yes No Cardio-vascular: Yes No GI: Yes No Blood, lymphatic: Yes No CNS (i.e. history of seizures): Yes No GU (i.e. STD): Yes No Past history of TB: Yes No Compromised immune system: Yes No Notes: 1. Physical Examination Height Weight BP Respiratory system: Abdomen: Range of Motion: Hair, skin, nails: (i.e. scabies or lice) Cardio-vascular system: Yes No Yes No Yes No Yes No Yes No Notes: 17

1. Is this Patient currently taking any prescribed medication Yes No If Yes please print name of medication, dosage and condition it has been prescribed for. (please note that our policy requires documented medication regime - no PRN) Name of Medication and Dosage 1. 2. 3. 4. 5. 6. 7. Reason for Prescription 2. Any current or recent medical problems which may require follow-up while in treatment? (Please attach a copy of recent lab work if applicable) 3. In your opinion is this patient able to participate in scheduled recreational activities (i.e. swimming, weight training, walking etc)? Yes No Comments: 4. Have you any comments or concerns about your patients physical and/or mental ability to participate in a group, 1 to 1 counseling and/or ability to live in a residential setting for six weeks? M.D Name Address: Phone # Fax Office Stamp Signature Date 18