‘Namgis Treatment Centre

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Namgis Treatment Centre

‘Namgis Treatment Centre

Application Package

The Client Application package is to be completed by the Referral worker and the

Client together. Client self- referrals are not accepted

Application Package includes:

Memo to: NNADAP Assessment and Referral Workers

Referral Worker Checklist

Application Package

Consent Form

Preadmission Medical Evaluation Form

Preadmission Medical Examination

939 TB Screen Test Form

Suicide Risk Assessment Form

‘Namgis Pre-treatment Agreements

Client’s Checklist

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Application Package _______________________________________________

Mary Hunt, Intake Coordinator

P.O. Box 290

Alert Bay, BC V0N 1A0

Phone: 250-974-5522 Ext. 2131

Intake Fax #: 250-974-2257 or Alternate Fax: 250-974-2736

Email: [email protected]

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To: NNADAP Assessment and Referral Workers

As we understand the struggle of addiction, so is the struggle for change and recovery. Through intake outcome evaluation, the ‘Namgis Treatment Centre (NTC) have identified a few areas of the referral and intake process that need to be addressed.

We are sending out an updated Referral Package and ask that you review the criteria for intake with your client. Often we receive referrals that are missing important information and look to improve the quality of service with the intake process.

Here are a few items that have cause to be addressed:

Clean Time: We require a minimal ten (10) days substance free and to be clear of medical detoxification.

Medications: All prescriptions up to date and in a blister pack if needed. Prescribed narcotics will not be dispensed during the six week program.

Probation: Clients on probation are required to submit a copy of their probation order prior to entering the program.

Court issues: Court dates are not to fall during intake dates. Referrals will be screened by a review panel and decision made pending the nature of the offence. We do not accept sex offenders.

Travel: Travel costs are the responsibility of the referral worker to arrange with the client. We ask that that you have pre arrangements for return travel in case the client decides to leave the program before completion or is discharged early for inappropriate group behavior.

Preparedness and Readiness: Residents will be orientated to house chores and guidelines in the first week of the program. In order to focus on their work, residents are to insure business matters are taken care of prior to arriving.

The Staff of the ‘Namgis Treatment Centre appreciates the good work you do in helping those reaching out. We continue to seek program improvement and welcome suggestions of how we can better serve the referral process. In Care and Respect Patrick Davis NTC Program Manager

‘Namgis Substance Abuse

Treatment Centre Society

P.O. Box 290, Alert Bay B.C., V0N 1A0

Ph: (250) 974-5522 Fax: (250) 974-2257

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TO ALL REFERRAL WORKERS: CHECKLIST

To confirm that the Checklist has been reviewed by the Referral worker and the Client, signatures are required at the bottom of page # 2 of this Checklist. (**Please return pages 1 & 2 of the Checklist**) Prior to Submitting this Application package please ensure that your client/s meet the following criteria listed below:

□ Client must attend a minimum of 6 counseling sessions one (1) per week prior to the program intake date. Verification of sessions is required in Application Package.

□ Client is required to abstain from alcohol for a minimum of 10 days prior to the intake date.

□ Date of last use of alcohol? ___________________________________ □ Client is required to abstain from drugs for a minimum of 10 days prior to

the intake date. □ Date of last use of drugs? ____________________________________ □ Client is required to state all Legal information any omission of Legal

issues can/will be grounds for dismissal from the program. □ Clients who have upcoming Legal Pending issues will Not be accepted. □ If the Client is Terminated/Self Terminated from the program, the client is

responsible for his/her own travel costs home. □ If Client is on Probation, a letter from the Probation Officer stating the

conditions of probation and expected reporting requirements of the client during the 42 day duration of treatment is required. A copy of the Probation Order/s is also required to be included with the Application Package.

□ Client has NO outside commitments during the 42 day session. (e.g. No Court appearances, Lawyers, Doctor’s, Dental appointments. Family responsibilities Etc.)

□ Client is aware of what is necessary to bring and what not to bring with him/her when coming to treatment.

□ Client has committed himself/herself to completing the 42 day program. □ Client has read and understands this Application package. □ Client/Referral worker have worked together to complete all forms for this

Application package. □ As the Referral worker you take the responsibility to ensure that all forms

are complete, and all necessary arrangements are made for your clients, such as travel, comfort allowance, etc... Signatures are signed where required, and that the client meets all requirements for this application package.



P.O. Box 290 Alert Bay B.C., V0N 1A0

Ph: (250) 974-5522 Fax: (250) 974-2257

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Referral workers please complete the Application package with your client/s. Please Print legibly. All questions are to be completed in the application package. If no response is required please enter N/A. Signatures are compulsory where indicated. All information is important in processing your client’s application.

If your client’s Application Package is INCOMPLETE your client’s application package will be returned to you for completion.

Namgis Treatment Centre is funded for Status Indians and Inuit clients.

Non Status individuals will be considered pending clients have their own funding in place to cover their stay at treatment and bed availability.

We are a six (6) week, 15 bed, Co-ed program. (19 and over only)

Individuals who are currently incarcerated can Not apply at this time, he/she can apply when they have been released into their community for a minimum 30 days.

We limit the number of clients per session with legal orders in place. (Which include those who are: Court Ordered, Ministry Ordered or on Probation.)

We do not accept clients who are on the Methadone Program.

We do not accept clients who are pregnant due to Medical concerns.

To ensure that you are sending in a COMPLETE Application Package please use the check list below.

□ Referral Worker Check list, completed and signed by Referral worker and Client □ Application for Treatment package □ Consent for Treatment □ Preadmission Medical Evaluation □ Preadmission Medical Examination □ TB Screen Test Results (939 Form included in package) □ Chest X-ray is Mandatory if client has a positive result on TB skin test. □ Copy of Probation order if applicable □ Suicide Risk Assessment Form □ Agreements

Thank you if you have any questions please contact us at the ‘Namgis Treatment Centre. Ph.: (250) 974-5522 ext. 2131 Fax: (250) 974-2257 or alternate fax: 250-974-2736

*Referral worker signature: _________________________________

*Client signature: __________________________________________

Date: ____________________________________________________

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NAMGIS TREATMENT CENTRE Application Package

Personal Identification Application Date: _____/_____/_____ PLEASE PRINT LEGIBLY Day Month Year

Last Name (legal): Birth Last Name (if different) (Please Print) (Please Print)

First Name(s): Known As: (Nickname): ____________________ (Please Print) (Please Print)

Middle Name: ___________________________ Gender: ____ Male ____Female

Personal Health Number (PHN) __ __ __ __ __ __ __ __ __ __ (10 DIGITS) Birth Date: _____ / _____ / ________ S.I.N. __ __ __ __ __ __ __ __ __ Day Month Year

Address: _________________________________ ____________________________________ City: Province: _____ Postal Code: ____________ Telephone #: ( ) _____________________Cell#: ( ) __________________________

Email: _________________________________ Living On Off Reserve Native Status: ___YES ___ NO ___ INUIT ______________________________________OTHER

Band #: __ __ __ __ __ __ __ __ __ __ Band Name: _______________________ (10 DIGITS) Ancestry/Nation: _________________________ Treaty # _____________________________

Marital Status:

Single Common-law Married Separated Divorced Widowed Emergency Contact: ______________Relationship: _________________________

Address: _______________________________ Telephone #: _________________________

-------------------------------------------------------------------------------------------------------------------------------

Referring Counselor Name: _____________________________________________________

Address: ____________________________________________________________________

Telephone: ___________________________ Emergency: _____________________________

Fax: ________________________________ Email: __________________________________

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Personal

1. Was the client raised on-reserve? YES NO

2. Has the client been raised by his/her natural parents? YES NO

3. Does the client state that addictions are a problem to his/her well-being? YES NO

4. Does the client state that sobriety is needed in order to change? YES NO

5. Are certain areas of the client’s life affected by substance abuse? YES NO

6. Has there been a death in the family due to substance abuse? YES NO

7. Number of children: At Home In Temp Care In Perm. Care

8. Any concerns about the safety of the children left at home? _____________________

9. Education: Residential Public ___ Gr. Completed Problems reading YES NO

10. Is there a history of physical abuse, or sexual abuse ____ ? ___________________

11. Any other significant events? _____________________________________________

__________________________________________________________________________

Personal Relationship

1. How long has client been involved in present relationship? ____________________________

2. Relationship strengths: ____________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

3. Relationship weaknesses: __________________________________________________

_____________________________________________________________________________

4. Relationship Breakdowns: __________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Comments: ___________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

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Dietary

Food Allergies: YES NO _________________________________

Eating Disorders: YES NO _________________________________

Special Diet: YES NO _________________________________

Does client eat Traditional Foods? YES NO

If not, willing to try? YES NO

Comments: ___________________________________________________________________

_____________________________________________________________________________

Employment

Usual Occupation: _____________________________________________________________________

Current Employment Status:

Full Time Part Time Laid-off Unemployed

Has your dependency on drugs or alcohol affected your employment status? YES NO

If Yes, how? __________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Comments: ____________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Spiritual/Cultural

Spiritual/Cultural Involvement _____________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Is the client involved in any spiritual/cultural activities? __________________________________

_____________________________________________________________________________

_____________________________________________________________________________

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Legal

It is Mandatory to complete ALL of the Questions on this page.

* Does your client have any Past Legal issues? YES NO What? _________________________

*Does your client have any Present Legal issues? YES NO What? _____________________

*Any Probation in the Past YES NO Length of Supervision: ______________________

* Any Probation Present YES NO Length of Supervision: ______________________

Alcohol or Drug related: YES NO

* Federal Provincial * Date of Release: / / Day Month Year

Alcohol or Drug related: YES NO

Personal Development courses taken while in Institution

____________________________________________________________________________________

Client must be Free from Incarceration 30 days before applying for treatment

Have you been charged in the last seven (7) years with:

A Non Indictable Offense Yes___ No ___

An Indictable Offense Yes___ No ___

Both Yes___ No ___

*Offense: ______________________________________________________________________________

* Any previous convictions? Yes No If yes, for what? ________________________________

* Any charges pending? Yes No If, yes, what charge? _____________________________

Any Court Dates Pending? Yes No If, yes, what date? ______________________________

*License suspension Yes No If yes, how many __________

* Impaired conviction Yes No If yes, how many __________

Alcohol or Drug related: Yes No

* Post-Treatment A/D Counselor and Agency: _________________________________________________

Address: ________________________ City: _________________________ Postal Code: ____________

* Probation Officer: _______________________________________ PO Phone #: _____________________

Address: _____________________________________________ PO Fax #: _______________________

City: __________________________ Postal Code: _____________ PO Email: _______________________

* Referral Worker Initials required ___________ *Client Initials required ____________

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Social/ Support

1. Client’s support network: _______________________________________________________

_____________________________________________________________________________

2. Where does client seek support? _________________________________________________

3. What supports are available to client on discharge? __________________________________

_____________________________________________________________________________

Referral Information: Please check one of the following boxes: □ A& D □ Doctor. □ Nurse

□ CHR □ Social Worker □ Probation Officer □ Mental Health Worker □ Other ______________

Referring Officer: Referral Date: _________________________

Agency: ______________________________________________________________________

Address: _______________________________ ______________________________________

Telephone #: ___________________________ Emergency #: _________________________

Fax: ___________________________________ Email: _______________________________ Name of A& D Counselor if different from the Referring Officer: ___________________________

Agency: ______________________________________________________________________

Address: ______________________________________________________________________

Telephone: _____________________________ Fax: __________________________________

History of Substance Abuse- Drugs Abused

TYPE

**NOTE: Put a circle around primary drug(s) of choice.

None Rarely Monthly Weekly Daily Age of First Use

Alcohol ( beer, wine, hard liquor)

Marijuana, Hashish

Inhalants (glue, paint), Sprays - solvents

Cocaine (e.g. crack, coke)

Stimulants/Amphetamines

Opiates-Morphine, Heroin, Dilaudid

Tranquilizers-Ativan, Valium, Librium, Zanax

Hallucinogen – LSD, PCP, dust

Painkillers – Codeine, Percodan, Lalwin

Tobacco – Other

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Abuse History

1. Have you ever had: DTs, Blackouts, seizures, hallucinations? YES NO

Describe: __________________________________________________________________

2. Needle use? YES NO

3. Shared needles? YES NO

4. Practice safe sex? YES NO

5. Withdrawal symptoms after stopping? ____________________________________________

_____________________________________________________________________________

6. Have you attended residential substance abuse treatment before? YES NO

If yes, where/when?

____________________________________________________________________________

Which one/s did you complete? __________________________________________________

Have you previously attended Namgis Treatment Centre? _______________________________

How Many times: ___________________________ When? _____________________________

Alcoholics Anonymous? A) Involvement YES NO

B) Sponsor YES NO

C) Amount of contact ___________________________________

1. Have you received psychiatric services previously? YES NO

Comments: ____________________________________________________________________

_____________________________________________________________________________

Medical/Psychological

1. Significant Medical Issues? _____________________________________________________

_____________________________________________________________________________

2. Significant Psychological Issues? _______________________________________________

_____________________________________________________________________________

Presenting Problems

1. Presenting events: ___________________________________________________________

_____________________________________________________________________________

2. Is attendance: Court ordered ___ Ministry of Child & Family Services ______ Other ______

3. If ordered, contact: Name _____________________________________________________

Organization: _______________________________________________________

Address: _______________________________________________________

Phone: ________________________ Fax: _________________________

Comments: ___________________________________________________________________

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Client’s Perspectives

1. What are the client’s perceptions of his/her addiction? _______________________________

_____________________________________________________________________________

2. Client’s wants/expectations? ___________________________________________________

_____________________________________________________________________________

3. Other concerns: _____________________________________________________________

_____________________________________________________________________________

Comments: ____________________________________________________________________

_____________________________________________________________________________

Counsellor Perspectives

1. Client’s emotional state: _______________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

2. Client’s insight: ______________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

3. Level of client’s motivation: ____________________________________________________

_____________________________________________________________________________

4. Does client have a discharge plan? YES NO

Comments: ___________________________________________________________________

If the client is Terminated/Self Terminated the Client/Referral worker is responsible for the client/s travel

costs home. (No exceptions allowed)

A Minimum of 6 (Six) counseling sessions 1(One) session per week is mandatory for client/s to attend

before coming to treatment.

Counseling sessions can be with an: A & D Counselor, Healing Circle, An Elder, AA meeting, NA

meeting,

Support group, etc. Date of Sessions and with whom:

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

4. ___________________________________________________________________

5. ___________________________________________________________________

6. ___________________________________________________________________

*Counselor Signature: _________________________________________________________

*Client Signature: ____________________________________________________________

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Consent for Treatment

I, ___________________________, agree to enter the ‘Namgis Treatment Centre for the purpose of treating my

alcohol/drug dependency problems.

I agree to attend a Minimum of six (6) counseling sessions prior to attending treatment.

I also agree to be involved in Alcohol/Drug Outpatient Counseling after attending the ‘Namgis Treatment Centre.

I understand the explanation of the above points of the “Namgis Treatment Centre Program, I therefore consent to

undergo treatment at the Namgis Treatment Centre.

Comments:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Consent for the Release of Confidential Information

I hereby give my permission for staff of the ‘Namgis Treatment Centre to contact:

Referral Worker ___ Social Worker ___ Probation Officer ___ Lawyer ___

Other: ______________________________________________________________________________

For information to be released which shall be limited to:

(i.e. progress during treatment, progress reports)

______________________________________________________________________________

*CLIENTS SIGNATURE: ___________________________________ DATE: ___________________

*REFFERAL WORKERS SIGNATURE: _________________________________________________

PRINTED NAME OF WITNESS/REFERRAL WORKER: __________________________________

REFFERAL AGENCY: _____________________________ TELEPHONE: ____________________

ADDRESS: ____________________________________ POSTAL CODE: _____________________

ALTERNATE CONTACT PERSON: ___________________________________________________

(If possible, for confirmation or admission processing only – not to be included in the release of confidential

information prior to, during, or after treatment.)

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‘NAMGIS TREATMENT CENTRE

PRE-ADMISSION MEDICAL EVALUATION

Date: ____________________________

Client’s Name: _____________________________ Date of Birth: ________ ________ _______

Please Print Day Month Year

Personal Health Number: __ __ __ __ __ __ __ __ __ __ __

A & D Counselor’s Name: ______________________________

Please Print

Referral Agency: _____________________________________

Phone: (______)__________________________ Fax: (_____)____________________________

CLIENT RELEASE OF MEDICAL INFORMATION

I, ____________________________________, hereby request and permit my physician, to release medical facts

and assessments about me to ‘Namgis Treatment Centre and the above named A & D Counselor. The photo-copy

fax of my signature on this form is as valid as the original.

*CLIENT’S SIGNATURE: _________________________________________

DATE: _________________________________________________________

TO THE PHYSICIAN:

The above client is to be medically assessed as a potential participant in our six (6) week residential life

skills program. Our program is designed to help people who acknowledge their drinking or drug use has

interfered with their effective functioning and who are physically and mentally ready to participate in a

program of intense counseling activity. As a counseling program and not a psychotherapy program the

‘Namgis Treatment Centre requires a client to have a complete physical examination prior to admission.

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Pre-Admission Medical Examination

(Please Print Legibly)

Date of Exam: ____________________________

Name: _______________________________Date of Birth: _______ _______ _______

(Please Print) Day Month Year

Are you the family doctor for the above individual stated? □ Yes □ No

1. A) Date of last alcohol use: __________ __________ __________

Day Month Year

B) Smoker Yes _____No____ Date Quit ___ ______ ___ Current ______ per day

Day Month Year

2. Date of last psychoactive drug use: ___________________ __________________________

(Please Print) Day Month Year Name of Drug

_______ __________ _________________________

Day Month Year Name of Drug

3. Current Medications: Dosage, Frequency and reason for Medication (Please Print Legibly)

___________________________________________ _______________________________________________

__________________________________________________________________________________________

___________________________________________ _______________________________________________

4. Previous or current psychiatric condition: ________________________________________

5. A) Current medical condition (s) list: ___________________________________________

____________________________________________________________________________

B) Any previous/current conditions?

______________________________________________________________________________

6. Medical problems to be followed while in treatment (M.D. is available for follow up). Please give

details:

______________________________________________________________________________

7. Is this patient Pregnant? Yes ______ No _______ Not applicable _______

8. TB Screen: Please use the 939 form provided in your application package.

If Mantoux Skin Test is Negative – No further action is necessary.

If Positive result (Past or Present) Chest X-ray is required. Please submit results of Chest X-ray.

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Past/Current History:

9. Is there any disorder of the following? Please Circle

a. Hair, skin, nails (especially current or recent infestations or infections YES NO

b. Ear, nose, throat YES NO

c. Musculo skeletal system YES NO

d. Blood, lymphatic system YES NO

e. Cardio vascular system YES NO

f. Respiratory system YES NO

g. G.I. system YES NO

h. G.U. system YES NO

i. CNS – especially hx of seizures YES NO

j. Past history of TB YES NO

If yes to any of the above please give details:

_________________________________________________________________________________________

_________________________________________________________________________________________

10. Family History: Alcohol/Drug Problem YES _____ NO _____

Psychiatric History YES _____ NO _____

Adopted YES _____ NO _____

11. Physical Examination: Ht. __________ Wt.__________ B.P. __________ P. __________

Normal Abnormal

a. Appearance _______ _______

b. E.N.T. _______ _______

c. Hair, skin, nails _______ _______

d. Reticuloendolhehial system _______ _______

e. Musculo skeletal system _______ _______

f. Thyroid _______ _______

g. Cardio vascular system _______ _______

h. Respiratory system _______ _______

j. Central nervous system _______ _______

k. Evidence of sexually transmitted disease _______ _______

l T.B. test _______ _______

m. Dental _______ _______

12. Give details to Re: abnormal notations:

_____________________________________________________________________________________________

This client should not require acute medical care at time of Treatment Centre admission. Diseases are to be under

control as much as possible, especially communicable diseases.

I have examined this client and find him/her to be fit to attend residential treatment.

PHYSICIAN’S SIGNATURE: __________________________________________

PRINTED NAME: ____________________________________________________

ADDRESS: __________________________________________________________

PHONE: (________)___________________________________________________

FAX: (________) _____________________________________________________

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To be completed by Referral Worker only:

Client Name: __________________________

Suicide Risk Assessment Form

1. Have you thought about killing yourself in the last 3 months?

Yes No

2. Have you ever thought about killing yourself or attempted to kill yourself before?

Yes No

If either of these (question #1 or #2) is yes then you must go on to ask the following questions

and assess risk factors.

3. On a scale of 1 – 10 where 10 is absolutely unbearable, how much pain are you in?

(1 being lowest level of pain and 10 being the highest level of pain)

_______________________________________________________________________________

_______________________________________________________________________________

__________________________________________________________

4. If you are thinking of killing yourself do you have a plan?

_______________________________________________________________________________

_______________________________________________________________________________

__________________________________________________________

5. If so, what is your plan? Or have you thought about how or when you may make your attempt

(Notice: immediacy, certainty, lethality & accessibility)

_______________________________________________________________________________

_______________________________________________________________________________

__________________________________________________________

6. What are some reasons to stay alive? Who can you talk to? (Or what are some things you

were looking forward to before this pain?)

_______________________________________________________________________________

_______________________________________________________________________________

__________________________________________________________

***If appropriate further explanation can be done by asking, “Tell me more about that….”

***Important to notice verbal and non-verbal messages being communicated & note them.

Risk Factors:

Addiction

Child Abuse

Childhood Abuse

Spouse Abuse

Depression

Increased Isolation

Preoccupation with

death

Hopelessness

Impaired Judgment

Recent Loss

Self Injury

Lack of social support

Previous MH/SA

hospitalization

History of mental health

concerns

Family history of

suicide/violence

Previous Suicide attempt

Self-destructive or risk-

taking behaviour

Other:______________

_

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Please Circle Level of Risk: Low Medium High

Low Risk Medium Risk High Risk

Pain (1 – 10) Level 1 – 5/10 6 – 8/10 9 – 10/10

Plan No specific plan

No available means

Aren’t certain want to die

Planned but not

immediate risk

Plan has possibility of

intervention

Aren’t sure want to die

Immediate

Date/time planned &

prepared

Referral Workers task:

1. Validate – focus on strengths and personal resources

2. Identify supports/resources (with phone numbers)

3. Risk Specific Responses

Low Risk

Action plan

Medium Risk

No Harm Agreement

24 hour supervision available if needed

Suicide means removed from home

High Risk

Emergency referral to suicide specific resource or escort to

Hospital or call ambulance/police for assistance if needed

24 hour supervision in place

Suicide means removed from home

4. Consult with Supervisor and Document

5. Inform Parents/Family

6. Follow-up with Longer Term Resources

7. Take Care of Yourself

***To protect you from any legal consequences it is essential you always record your suicide risk

assessment on paper and consult with a mental health professional when risk is medium or high.***

1. Concrete Goal 2. Resource

3. Another Meeting

___________________ ___________________

___________________

___________________

1. Promise 2. Suicide Specific

Resource 3. Another Meeting

___________________ ___________________

___________________

___________________

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Namgis Pre-treatment Agreements

The Pre-treatment Agreements:

Consent for Treatment

Client Charter of Rights, Responsibilities and Agreements

Confidentiality Oath

These must be read, and signed by the Referral Worker and the Client/s together.

Please return the Agreements to the Namgis Treatment Centre as soon as possible.

Any questions or for further information, please contact me @ 250-974-5522 ext. 2131 or

By email [email protected]

Mary Hunt Namgis Treatment Centre Intake Coordinator

‘Namgis Substance Abuse Treatment Centre Society


Ph.: (250) 974-5522 Fax: (250) 974-2257

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CONSENT FOR TREATMENT

I _____________________ (Name of Client) understand that my participation in the Substance Abuse Program at the Namgis Treatment Centre requires that I am:

Aware that the Namgis Treatment Centre program is a continuous six- week program, which begins upon my arrival and ends following the completion ceremony.

Aware that there is a schedule of events and activities which will require my full participation, and

Aware that if I am UNWILLING to participate fully, I may be asked to leave. I understand for the client and staff to work effectively, the treatment program will include:

Counseling assessments and treatment plans

Arts and crafts, recreational activities, and ceremonies

Group therapy sessions/life skills training/sessions with elders/assignments

Alcoholic Anonymous/Narcotics Anonymous meetings

Contact with my referral sources, and

Maintenance of confidential client records as stated in the Privacy Act

I understand that applicants have been referred from NNADAP, Friendship Centres, Social Workers, Doctors, Detox, Employers, Alcohol and Drug Counselors, and Parole. I understand treatment is a continuum. Therefore, I agree to be involved with after-care.

I am aware that according to the Family and Child Services Act, staff at Namgis Treatment

Centre are required to report to the appropriate authorities any information received regarding the abuse of any individual presently under the age of nineteen (19). I understand the explanation of the above points and the above named Agency’s program and guidelines and I therefore, consent to undergo treatment at the Namgis Treatment Centre. I am aware that whenever people gather, such as at home communities, social and spiritual functions, family and treatment programs, etc., there may be identified and unidentified sexual offenders present. This is also true of Namgis Treatment Centre.

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I also understand that I can withdraw or amend my consent to the release/request of information at any time. *Client’s Signature: Date: *Witness Signature: Date:

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Namgis Treatment Centre Client Charter of Rights, Responsibilities and Agreements

1. I acknowledge that I have the right to be treated with dignity and respect. 2. I acknowledge that I have the right to be treated as a unique and valuable

individual in a non-discriminatory manner. 3. I acknowledge that I have the right to begin dealing with my addiction and related

issues in an environment that is safe and free of all forms of abuse. 4. I acknowledge that I have the right and responsibility, to question things that I do

not understand or agree with. 5. I acknowledge that I have the right to accurate and complete information

regarding the extent, nature and limitation of any service that is being provided. 6. I acknowledge that I have the right to make a complaint about something that I

do not agree with, or that makes me uncomfortable. 7. I acknowledge that I am responsible for taking part in the daily scheduled

programming to be on time and to participate fully. 8. I agree not to use alcohol or other drugs while I am participating in this program

– it jeopardizes not only my recovery, but the recovery of others as well. 9. I acknowledge that I am responsible for helping to maintain a safe, drug and

alcohol free environment and agree to let staff know, if I become aware that anyone is using alcohol or drugs, or making the environment unsafe for others, in some way.

10. I acknowledge that there are stressors/triggers that may overwhelm me from time to time if I am overwhelmed or are at risk of harm to myself or others that I will speak to my one to one worker.

11. I acknowledge that need for guidelines for my relationships with other residents of the program. I agree that any physical contact that I have with another client in the program will be appropriate, non-romantic, and non-sexual. I agree that I will not have ANY physical, sexual or romantic contact with any client in the treatment program, any staff member, or any community member.

12. I acknowledge that I have the right to be free from all forms of sexual harassment. I agree that I will refrain from all forms of harassment, including suggestive remarks and looks.

13. I acknowledge that my reason for coming to the Namgis Treatment Centre is to concentrate on beginning/continuing my recovery and agree to take care of all outside issues prior to admission and to focus on my recovery while in the program.

14. I acknowledge that it is my responsibility to follow the behavior guidelines as outlines in the program – they have developed for everyone’s comfort and protection. I acknowledge that if I violate those guidelines, I may be required to leave the program.




Ph: (250) 974-5522 Fax: (250) 974-2257

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Namgis Treatment Centre Client Charter of Rights, Responsibilities, and Agreements

15. I acknowledge that I am responsible for treating the other clients in a fair and considerate

way and agree to strive to treat them the way I wish to be treated.

16. I acknowledge that I am responsible for my own recovery and agree to make every attempt to begin looking at and thinking about myself and my life, in new ways that are positive and life affirming.

17. I acknowledge my right to have my confidentiality protected and recognize that I am responsible to help protect other’s confidentiality. I agree not to tell anyone outside of the program about people who have been at the Namgis Treatment Centre and agree not to talk about things that are disclosed in our groups.

Client Name: (Please Print) *Client Signature: Date: *Witness: Date:

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CONFIDENTIALITY OATH

I, ____________________, hereby swear the following oath of confidentiality:

I swear, that any confidential

Information that is shared by fellow clients and, counselors will be held in the Strictest of confidence.

Failing this, I will be subject to the

Disciplinary actions of the Namgis Treatment Centre.

__________________ __________________

* Client Signature *Witness Signature __________________ Date

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Client Checklist

Referral Worker please give this Checklist to your client/s prior to him/her coming to treatment. If your

client/s has/have difficulty reading, please read and review this checklist with your client/s.

Please Bring These Following items with you when attending treatment:

Comfort Allowance (For six weeks.) We strongly suggest Direct Deposit, an ATM may not available.

Personal Identification suggested: Status Card, Birth Certificate, BC ID, PHN card, Driver’s

License, etc.

Please bring loose comfortable clothing such as a jogging suit for your use during exercising.

Personal Medication: Physician prescribed. If possible please have all medication in Bubble

packages for the six- week stay. (All medications are to be handed over to the NTC staff when client

arrives for Treatment)

* Shampoo & Conditioner *Toothbrush & toothpaste, and Dental floss *Comb & Brush *Deodorant/ Body wash * Shaving equipment * Running shoes * Appropriate Daily clothing * Slippers *Pajamas/robe * Personal sundries

*Writing paper/envelopes/stamps *Personal Arts & crafts

The following are optional:

Family photos, Camera, Dress clothes/dress shoes for graduation, Travel Mug/Cup or

Water Bottle

The following items are NOT permitted:

X - Laptop computer X - Personal DVD player/DVD’s X - MP3 Player X - iPod

X - CD Player/CD’s X - Cassette Player/Cassettes X – Personal Phone X – Radio

X - Alarm clock X - Video Camera X - No hand held Electronic games of any kind

X - No over the counter medications X - No low cut or revealing clothing

X - Absolutely No Junk Food permitted (Chips, pop, gum, candy, etc.)

If any of the above items are brought with client to treatment the item will be handed in upon entrance and

will be return when the client is ready to leave treatment.

If the client travels to treatment with personal vehicle the keys will be handed into a Staff member upon

arrival and the vehicle will remain parked until the end of the Treatment session.

Referral worker please ensure that your client/s has their comfort allowance and return travel

arranged before they attend treatment. Eg. Bus ticket, plane ticket, ferry tickets, etc. Thank you.

Documents

‘Namgis Treatment Centre