APPLICATION FOR SERVICES
c *6 Week Residential
c Matrix Program
c Home Visits
c Outpatient Sessions
*Medical Form Required
DATE: ______
Part A: INFORMATION ABOUT THE CLIENT
Last Name: ______First Name: ______
Date of Birth: ______Age at present: ______Female Male
Month day, year
Address:______House number:______
Phone Number: (___)______Cell Number: (___)______Alternate Phone: (___)______
First Nation’s Reserve Name: ______Province: ______
Registration Status Number (10 numbers): ______Band Number (3 Numbers):______
Marital Status:
Married c Separated c Divorced c Single c Common-Law c Widowed c
Health Information:
Provincial Health Card Number: ______Expiry Date (Month day, year): ______
Family Physician: ______Phone Number of Physician: (___)______
ALLERGIES:______
Are you allergic to ANY medications? Yes c No c If yes, please list:______
Are you currently on ANY medication? Yes c No c
If Yes, list ALL prescribed and over the counter medications you plan to bring to treatment:
______
______
Next of Kin/Emergency Contact Information
Next of Kin: ______Relationship: ______
Next of Kin’s Home Phone: ______Work: ______Cell: ______
Next of Kin’s Address: ______
Emergency Contact Person: ______Phone Number: ______
Address: ______
Employment Status and Income Source:
Un-Employed c Self-Employed c Temporary c Retired c Receiving Pension c
Student c Homemaker c Job Training c Permanent job c Seasonal Worker c
Occupation: ______
E.I. c C.C.T.B. c Job c Pension c Parents c S.A. c
Spouse c Other c None c
Education: What level of education do you have?
Elementary c Junior High c High-school c Adult Education c
No Education c Post-secondary c Other:______
Education Location:
Boarding School c Public Off Reserve c Private School c Day School c
Residential School c Public On Reserve c Home schooled c
Legal Status:
Parole c Probation c Currently Incarcerated c
Do you have any pending charges: Yes c No c If yes, please explain: ______
Were you under the influence when the crime(s) were committed? Yes c No c
Court Appearance: Yes c No c If Yes, When and where: ______
Is your attendance required by law? (Probation/Orders etc.) Yes c No c
Is there anything or anyone that will affect your completion of the program you are applying for?
If yes, please explain: ______
Current Living Situation:
Extended Family c Alone c With Friends c
With Spouse c With Parents c With Spouse & Children c
Living on Reserve c Living Off Reserve c
Were you raised on reserve? Yes c No c
Were you raised by your biological parents? Yes c No c
If No, with whom were you raised? ______
Children:
Do you have children? Yes c No c If yes, how many do you have? ______
Are they/have they been apprehended, or in care? Yes c No c
If apprehended, how long have they been apprehended? ______
Is your attendance to treatment required by Child Protection Services? Yes c No c
Did you drink alcohol while you were pregnant? Yes c No c
Did you use drugs while you were pregnant? Yes c No c
Have you ever given up a child to be adopted? Yes c No c
Have you had a significant loss? Yes c No c
If yes, please explain: ______
SUBSTANCE USE INFORMATION SYSTEM
Ingestion Score
1 - Within the last 24 hrs. 2 - Within 2 to 7 days 3 – Within 8 to 30 days 4 – Over a month ago
Drug Classification / Substance / Age ofFirst time use / Frequency
# Per
month week day / Date of Last use
Cannabis: / Hash Oil
Hash
Marijuana
Hallucinogens: / Ectasy
LSD
PCP
Angel Dust
Magic Mushroom
Peyote
Psilocybin
Narco-analgesics- Opiates (pain killers) / Ativan
Hydrocodone
Oxycotin
Oxycodon
Codeine
Demerol
Fentanyl
Substance / Age / week / week / day / Date of Last use
Seconal
Morphine
Methadone
Nembutal
Anytal
Tuinal
Tylenol 3
Ketamine
Mandrax
Dalmane
Halcion
Librium
Serax
Heroin
Clonazepam
Alprazolam
Buspirone
Cloral hydrate
Clorazepate
Diazepam
Flurazepam
Hydrorizine
Lorazepan
Midazolam
Prazepam
Propranolol
Xanax
Triazolam
Zephalon
Zolpidem
Talwin
Sedative/Hypnotics:
Stimulants: / Alcohol:
/ Beer
Wine
Hard liquor
Lysol
Hand sanitizer
Listerine
Rubbing alcohol
Substance / Age / month / week / day / Date of Last use
Benzodiazepine
Barbiturates
Trazodone
Desyrel
Luminal
Valium
Other Sleeping Aids
Solvent
Other: / Glue
Plastic Cement
Polish Remover
Dry Cleaner
Computer Cleaner
Gas
Paint Thinner
Lighter Fuels
Paint Spray
Cocaine / Cocaine
Crack
Ice
Meth
Nicotine-
Tobacco:
/ Cigars
Cigarettes
Snuff
Caffeine / Energy drinks
Coffee
Ritalin
Amphetamine
Mescaline
Speed
Other:
What is your drug of choice: ______
Which of the following areas have been negatively affected by your use:
School Attendance c Family Relationships c Physical Health c
Employment c Psychological Health c Legal Situation c Other:______
Do you think you have an alcohol and/or drug use problem? Yes c No c
Are others concerned about your alcohol &/or drug problem? Yes c No c
Have you ever attended Narcotic &/or Alcoholics Anonymous meetings (AA or NA)? Yes c No c
If Yes, did you have an AA/NA sponsor? Yes c No c
Number of AA or NA meetings attended in the past 6 months: ______
Do you have any following cross addictions?
Gambling c Relationships c Shopping c
Sex c Food c Internet c Other: ______
Impact: Which areas have been negatively affected by your use?
School Attendance c Physical Health c Family Relationships c Legal Situation c
Employment c Psychological Health c Friendships c Parenting c
Other ______
Situation: Did you drink or use drug…
Alone c With boss c With parents c With Cousins c
At home c With Co-workers c With Grandparents c With Uncles-aunts c
At parties c With Strangers c With Spouse c On weekdays c
In bars c In large groups c With Brothers/Sisters c On weekends c
At work c With small groups c With Friends c
Family of Origin use History:
Is there any history of alcohol/drug use in your family of origin? Yes c No c
Relatives / Uses alcohol / Uses drugs / Never met this relative / Deceased.Year of death: / In close contact / Some contact / No contact
Grandmothers:
Grandfathers:
Bio Mother
Adoptive Mother
Bio Father
Adoptive Father
Foster Parents
Brothers:
Sisters:
Children:
Risk Assessment:
Have you ever thought about hurting yourself? Yes c No c If yes, when was the last time? ______
Have you ever attempted suicide? Yes c No c If yes, when was the last time? ______
If yes, how many times? ______Please tell us how? ______
How many people have you lost to suicide?______
Affiliations:
Are you affiliated with street gangs? Yes c No c
If yes, please explain your affiliation:______
Previous Residential Treatment:
Type / Where?(city/ province) / Year / Length of program / How many times?
Hospitalization for detox
Alcohol/drugs/solvent abuse
Trauma related to the Residential School
Post-Traumatic Stress Disorder (PTSD)
Hospitalization for psychiatric concerns
(e.g. anxiety, depression, psychosis, suicide attempt,
Self-Harming, Eating Disorder, etc.)
Previous Outpatient Treatment:
Type / Where? / How many times?Individual Counselling
Couple or Family Counselling
Sessions with an Elder
Participated in Traditional Healing Ceremonies
The Matrix Program
What is your religion? ______
Are you comfortable attending the following events:
Cultural Events Yes c No c Self-Healing Practices Yes c No c
Traditional Healers Yes c No c Church Yes c No c
*IMPORTANT NOTE: We are a Culturally Based First Nations Center. We accept all religions.
Areas of Interest Indicate what areas you would like to address while at the Ekweskeet Healing Lodge:
Domestic Violence as: Victim c Witness c Aggressor c
Sexual Abuse as: Victim c Witness c Aggressor c
Incest as: Victim c Witness c Aggressor c
Anger c Sadness c Hopelessness c Feeling lost c
Self-Harm c Abandonment c Grief c Parenting Skills c
Residential School/Intergenerational Impact c
Please explain what motivated you to apply for treatment.
______
PART B: REFERRAL AGENT QUESTIONS
Must complete all questions below.
Name of Worker/Counsellor: ______Title: ______
Name of the Organization: ______
Address of the Organization: ______
Telephone Number of Organization: (___) ______Fax: (___) ______
How many sessions have you have with this client?
Once c 5 times or less c 10 times or more c Other:______
Does the client need detox before admission into Ekweskeet Healing Lodge? Yes c No c
Check off any of the areas your client may want to deal with while in treatment:
Domestic Violence as: Victim c Witness c Aggressor c
Sexual Abuse as: Victim c Witness c Aggressor c
Incest as: Victim c Witness c Aggressor c
Anger c Sadness c Hopelessness c Feeling lost c
Self-Harm c Abandonment c Grief c Parenting Skills c
Residential School/Intergenerational Impact c
Are you aware of any factors in this client’s life (medical or legal) that may pose a threat to other clients in treatment? Yes c No c If yes, please explain: ______
Has your client been referred to and denied treatment at any other center? Yes c No c
In order for us to develop a treatment plan, does your client have any special needs that we should be aware of? Yes c No c If yes, please explain: ______
______
Has your client completed a SASSI or other format of addictions assessment? Yes c No c
Has your client attended any intervention activities in your community? Yes c No c
If yes, please explain: ______
What services will you provide for the after care of your client? ______
______
ORGANIZATION CONNECTED TO CLIENT
NNADAP Projects Out-Patient Clinics c Other Out-Patient Clinics c
CHR/NNADAP Worker c Justice Program c
Employment Assistance Program c Court c
Family c Police c
Self-Referral c Social Services c
Part C: Medical Form
To be filled out by a Medical Practitioner
Last Name of Patient: ______First Name of Patient: ______
Patient’s Date of Birth: ______Provincial Health Care Number: ______
Name of Medical Practitioner (Please include License Number): ______
Telephone number of Medical Practitioner: (____)______Fax: (____)______
Please examine the patient and indicate the presence of the following conditions and illnesses; as well as, status of treatment if applicable:
Condition/illness/concerns/details / Yes / No / Currently Treated / Cleared?Allergies:
Diabetes
Epilepsy or seizure disorders
Sexually Transmitted Infections:
Scabies
Lice
Cancer
Stroke
Tuberculosis
Cardiovascular Disease:
Hepatitis A, B or C:
High Blood Pressure
Emphysema or other Lung Disease
Psychiatric concerns:
Diagnosed Mental Illness:
HIV/ AIDS
Gastrointestinal:
Hypothyroidism or Hyperthyroidism
Pregnancy – Due date: DD / MM / YYYY
Back Pain
Is this patient stable enough to attend a 6 week residential treatment program? Yes c Noc
Does patient need medical detoxification before attending the 6 week treatment program? Yes c No c
Is this patient taking any Narcotic, Opioid, Sedative or Hypnotic medication? (Please list) Yes c No c
If yes, is there an alternative non-narcotic medication? (Please list)______
______
Is it safe for this patient to use a dry sauna while in treatment? Yes c No c
List all medications this patient is currently taking:
Medication Name / Dosage / How long the patient has been taking this medication? / Prescribed for:Special dietary requirements: ______
Are there any operations or serious illnesses within the past year that staff of the treatment facility need to be aware of? Give approximate dates, names of physicians or surgeons and results of treatment:
______
______
Are you aware of any factors in this patient’s life (medical history, etc.) that may pose a threat to other clients or staff? Yes c No c If yes, please explain: ______
______
______
VERY IMPORTANT
*PLEASE ENSURE THE PATIENT HAS AT LEAST 6 WEEKS OF NECESSARY PRESCRIBED MEDICATION BUBBLE PACKED*
______
Doctor/Medical Practitioner Signature Date (Month day, Year)
Part D: TB Screening
To be filled out by a Medical Practitioner
Last Name of Patient: ______First Name of Patient: ______
Patient’s Date of Birth: ______Provincial Health Care Number: ______
Name of Medical Practitioner (Please include License Number): ______
Telephone number of Medical Practitioner: (____)______Fax: (____)______
Please examine the patient and indicate the presence of the following conditions and illnesses; as well as, status of treatment if applicable:
TB Screening: Symptoms and history / Yes / No / Currently Treated / If yes, please comment:Presence of cough lasting more than 2 weeks
Weight loss ______#lbs. _____length of time
Night sweats
Fever
Fatigue
Hemoptysis (blood in sputum)
Recent or past exposure of TB
Previous active TB and treatment
Previous significant Mantoux results or Chest X-ray results
Extensive Travel (or birth) in a country with high incidence of TB
Other risk factors for infection (Living in an area with high incidence of TB, elderly, homeless, health care worker)
Poor general health status and risk factors for progression of disease
ACTIONS
Further TB screening or assessment required (if “yes” please fax results to Ekweskeet Healing Lodge)
*Please ensure the patient has at least 6 weeks of necessary prescribed medication bubble packed*
______
Doctor/Medical Practitioner Signature Examination Date (Month day, Year)
1
Revised May 20, 2015 (YH) (VP)