Brantford Native Housing Residential Support/ Addiction Treatment Program

Brantford Native Housing Residential Support/ Addiction Treatment Program Application Package Ojistoh House or Karahkwa House 318 Colborne Street East Brantford, ON N3S 3M9 (519) 753-5408 x 235 T (519) 756-1764 F

Brantford Native Housing Addiction Residential Support Program Application Process Background The Residential Support Addiction Treatment Program is offered through Brantford Native Housing. This program is offered to Aboriginal men (Karahkwa House) and women (Ojistoh House) (18 +) who are in recovery from drug and/or alcohol use. Residents can stay in the Residential Support Addiction Treatment Program for up to one (1) year and receive up to two (2) years of supports while residing in the community. Residents must have four months of abstinence from all alcohol and illicit drugs and have abstinence as your goal to qualify for the program. Brantford Native Housing provides addiction programming that incorporates both Aboriginal specific health and healing programming as well as cognitive behavioural and biopsychosocial addiction treatment models. Residents will be expected to maintain abstinence from all alcohol and recreational (mood altering) drugs while residing in the Residential Support Addiction Treatment Program and participate in programming. Application Process Brantford Native Housing Residential Support Addiction Treatment Program is transitional housing. It is expected that Applicants have attended an in-patient residential treatment program or received extensive outpatient treatment support. We require all incoming applications to be completed by a community service agency/addiction treatment program. Self referrals also accepted if references (agencies you are/have worked with) provided. Completed applications can be faxed to: Transitional Support Worker 519-756-1764 Once we receive the completed application forms, a Brantford Native Housing staff person will contact the Applicant within one (1) week to schedule an intake interview to assist in determining eligibility and obtain any additional necessary information for review of the application. Eligibility Criteria 1. At least 50% of the family (female Applicants bringing children) must be of Aboriginal ancestry. Male Applicants must be of Aboriginal ancestry; 2. Applicant must be in need of housing due to homelessness or at-risk of homelessness (i.e., living in a shelter, temporarily staying with family or friends, etc.); Brantford Native Housing Residential Support Addiction Program Application Page 2 of 13

3. The Applicant must be 18 years of age or older; 4. The Applicant must be eligible for Ontario Works, ODSP or other income programs, if not working or attending school or a training course; 5. Committed to paying service fees; 6. Committed to the aftercare program (if coming from a treatment program) and/or full abstinence from drugs/alcohol and participate in our treatment programming, which includes individual counselling, group counselling and attendance in a peer support group; 7. Committed to connecting with community resources and moving toward an independent and healthy lifestyle; and 8. Applicants must agree to sign our Consent to Obtain Information form with the referring community service agency and other service providers the Applicant is working with. Brantford Native Housing Residential Support Addiction Program Application Page 3 of 13

Residential Support / Addiction Program Application Form Ojistoh House (Female) Karahkwa House (Male) APPLICANT NAME: Date of Birth: Aboriginal Ancestry: First Nations Status Métis First Nations Non-status Inuit Applicant Band and Number: Applicant Address: Telephone/Fax: Email: APPLICANT DEPENDENTS: 1. Name: DOB: Age: Aboriginal Ancestry: Gender: 2. Name: DOB: Age: Aboriginal Ancestry: Gender: 3. Name: DOB: Age: Aboriginal Ancestry: Gender: 4. Name: DOB: Age: Aboriginal Ancestry: Gender: 5. Name: DOB: Age: Aboriginal Ancestry: Gender: Brantford Native Housing Residential Support Addiction Program Application Page 4 of 13

APPLICANT INCOME: 1. What is the Applicant s last source of income? 2. Does the Applicant receive child support payments? 3. Does the Applicant understand that she/he is required to pay service fees to stay in the Addiction Residential Support Program? Yes No REFERRING AGENCY INFORMATION: Name of Agency: Name/Position: Address: Telephone/Fax/Email: 1. Is the Applicant able to complete daily living chores? 2. Does the Applicant have any disabilities? APPLICANT INFORMATION: 1. Does the Applicant have any children that are not in their care and will not be staying with the Applicant? Yes No 2. Where is the Applicant presently living? Shelter Family/friends Hotel/Motel Other How long? 3. Are there any safety issues/concerns regarding current or past intimate relationships? Yes No Restraining order Peace bonds Custody orders CAS conditions Other If yes, please explain: Brantford Native Housing Residential Support Addiction Program Application Page 5 of 13

4. Is the Applicant on Probation or Parole? Yes No If yes, who is the Probation/Parole Officer? Contact info: 5. What other agencies/service providers is the Applicant currently working with? Ontario Works C.A.S Probation & Parole Mental Health Supports Counselling Legal Services Public Health Services Training Program Employment Services Other, please explain 6. History of Drug/Alcohol Use: Drug/Alcohol used Age when 1 st used Age when last used 7. History of Drug/Alcohol Treatment: Has the Applicant been to Detox? No Yes - Date Has the Applicant recently attended an Addiction Treatment Program? No Yes, where and when? Does the Applicant have an Aftercare Plan? No Yes (attach copy) Does the Applicant have a Sponsor? No Yes Brantford Native Housing Residential Support Addiction Program Application Page 6 of 13

8. What wellness steps has the Applicant taken? Support System Therapy/Counselling AA NA Anger Management Group Therapy Cultural Activities Other 9. Is the Applicant on the Methadone program? Yes No If yes, where does the Applicant access the meds and who manages their participation? Current Dose: Length of time in Methadone Program and history of dose: 10. What other goals will the Applicant be working on not related to substance use? 11. Who does the Applicant include as support during crisis? Name: Relationship Contact Information: Brantford Native Housing Residential Support Addiction Program Application Page 7 of 13

12. Emergency Contact Persons: Name: Relationship: Contact Information: APPLICANT EDUCATION: Some High School High School Grad GED Some College College Grad Some University University Grad Technical/trade certified Training APPLICANT WORK HISTORY: Is the Applicant currently employed? Yes No Employer: Address: Telephone/Fax: Position: Work hours: Salary/Wage per hour Does the Applicant have an up-to-date resume? Yes No Does the Applicant want to work? Yes No HEALTH INFORMATION: 1. Are there acute medical complications that may require referrals to emergency or hospital for immediate medical assessment? Yes No Brantford Native Housing Residential Support Addiction Program Application Page 8 of 13

2. When did the Applicant last see a physician? Doctor: Phone #: Address: 3. Does the Applicant have any life threatening allergies? Food Environment Medicine If yes, please explain: 4. Does the Applicant carry an Epipen for allergies? Yes No 5. Is the Applicant currently in any type of treatment or counselling for emotional or mental health problems? Yes, where? No 6. Was the Applicant hospitalized in the last year? If yes, for what reason. Yes No 7. List all current medications, dose and the reason for taking it. Medication Dose Reason for Taking 8. Health Screening: Check all that apply. Diabetes Epilepsy or seizures Cancer Eating disorders Heart disease High/Low Blood pressure Liver disease Kidney disease Asthma Menstrual/menopausal difficulties Brantford Native Housing Residential Support Addiction Program Application Page 9 of 13

Pregnancy Pancreatitis Physical or sexual abuse Emotional/verbal abuse Recent untreated injury Tuberculosis ~ TB Sexually transmitted disease Lice/scabies Stomach problems Tuberculosis Head injury Hepatitis A B or C Please add any additional information that will assist our understanding of the Applicant s needs. Brantford Native Housing Residential Support Addiction Program Application Page 10 of 13

Brantford Native Housing Addiction Treatment Program Brantford Native Housing provides a supportive residential addiction treatment program and an outpatient structured relapse prevention group and limited short-term individual counselling for individuals concerned about alcohol and drugs. This program is designed to help individuals review their lifestyle, identify changes they would like to make, and help them develop the necessary skills to make those changes. Referrals to residential treatment programs or community programs are provided. Consultation is also available for family members, friends or professionals who are concerned about someone else s use of alcohol or drugs. Services are provided free of charge. All sessions are by appointment only. During scheduled group times we are unable to provide immediate appointments. If you are in crisis please call: Nova Vita (Emergency Shelter 24 hour crisis line) 519-752-4357 St. Leonard s (Community Service 24 hour crisis line) 519-759-7188 or 1-866-811-7188 Clients arriving at the agency under the influence of drugs or alcohol will have their appointment rescheduled. All services are confidential within the agency, with five exceptions listed below: While attending services with Brantford Native Housing, what you discuss with your counsellor and group leaders is private and confidential to the agency. Your counsellor/group leader cannot and will not freely share any information about you to others outside the agency. This means that you must give permission in writing in order for us to release information about you to anyone else. There are exceptions, required by law, where information may be given out without your consent. These include the following: Suspected child abuse or neglect will be reported to the Children s Aid Society of Brant; When someone is intending on harming him or herself (i.e. suicidal) or someone else (i.e. homicidal); A subpoena or summons is served by the courts; When a person arrives under the influence of alcohol or drugs and insists on driving, the Brantford Police Department will be notified if alternative arrangements are refused; and Brantford Native Housing Residential Support Addiction Program Application Page 11 of 13

Cases of medical emergencies, the ambulance/medical personnel will be provided with your name and emergency contact information. Under the Personal Health Information Protection Act (PHIPA) it is important for you to understand how your personal health information is protected and how it is used. All workers at Brantford Native Housing are aware of the sensitive nature of your health information and have received training in the Acts and are sworn to an Oath of Confidentiality. If you are concerned about how your personal health information is collected, used or disclosed, you may file a complaint against Brantford Native Housing or an individual, through the Information and Privacy Commissioner of Ontario. At Brantford Native Housing, an assigned Intake Worker or designated Program Worker will collect your information. From time to time, you may be accessing more than one program or service. This consent form will serve for all Brantford Native Housing programs you are currently accessing. Your original consent will be kept in your primary program file (the service you have the most contact with). only necessary information is collected about you; your information is only shared by written consent (with the noted exceptions); and storage, retention, and destruction of your personal health information complies with our file maintenance policy, legislation and privacy protection protocols. NOTE: From time to time this information may be used to do studies/ research/ reports on issues specific to the health of urban Aboriginal peoples and for the purpose of procuring additional funding. At no time will any identifiable information be processed for such use. By signing the consent section of this Client Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal and health information for the purposes listed. Should a new purpose arise, we shall seek your approval first. You may withdraw your consent at any time for the collection, use, or disclosure of your personal health information by providing notice to your primary worker within Brantford Native Housing. You also can place a condition or restriction on your consent, in that you may choose to restrict all or part of your health information from being shared. You also have the right to access your own personal health information, through a written request to the Manager, Community Programs. Brantford Native Housing Residential Support Addiction Program Application Page 12 of 13

CLIENT CONSENT 1. I have reviewed the preceding information and had it explained to me and /or the person who is my legal guardian; or has my power of attorney, where necessary; on how Brantford Native Housing will use my personal information and personal health information. 2. I am also aware of the steps taken by Brantford Native Housing to protect my information, when it is collected, used or disclosed, as well as how it will be stored and destroyed. 3. I agree that Brantford Native Housing can collect, use and disclose personal and personal health information about myself, or for my children under the age of 12 as their legal guardian; or I have power of attorney for their health; or they are my child/children as set out in the above information. Applicant Signature Date Witness Date Brantford Native Housing Residential Support Addiction Program Application Page 13 of 13