Transcription of 35 DAY TREATMENT PROGRAM APPLICATION FORM
1 35 day treatment program application form This applic ation is the first step required to pre-screen applicants for adult TREATMENT at any of the NNADAP facilities listed below. Additional information may be required by individual centers before a decision on acceptance is made. Please check one: In-Patient TREATMENT PROGRAM : O Cree Nations TREATMENT Haven Box 340, Canwood SK, S0J 0K0 Phone: [306] 468-2072 Fax: [306] 468-2758 Email: We bsite: www .cree nationstreat Out-Patient TREATMENT PROGRAM : O Cree Nations TREATMENT Haven MATRIX Outp atient TREATMENT PROGRAM Bo x 34 0, Canwood, SK, S0J 0K0 Phone: [ 306 ] 468-2072 Fax: [306] 468-2758 Office use only Trea tment Centres Registration Date: Admission Date: Actual admis sion date: Cancellation date: 2 35 day treatment program application form Part 1 Client APPLICATION : A.
2 General Information Surname:_ First N ame [s]: Nick nam e: Gende r: O Mal e O Female Date of birt h::_ Status Indian: O Yes O No First Nation /Ba nd Na me:_ Band Number: Tr eaty Number:_ Health Insura nce Number: So cial Ins uran ce Number: Add res s [ Home]:_ City: Province: Posta l Code: Pho ne: Marital Status: O Si ngle O Married O Common law O Widowed O Divorced O Se para ted Family Type: O Living al one O With spouse O With spouse & children O With friends O Single par ent with chi ldren O With ex ten ded fa mily Number of ch ildren and ages: _ Do your children live with you ?
3 O Yes, if not all, how many ? O No Ed ucati onal lev el: O Grade 1 6 O Grade 6 9 O Grade 9 12 O Post seconda ry Employment: O Fu ll-time job O Par t- time job O Unemployed O Se asonal work O Home mak er O St udent Emergency Contact: Name:_ Relationship: Add ress: Hom e Phone: Fax Number: Work Phone: Ema il: 3 B. Substance Use Profile Substances Used: A: Last 24 hours B: 2-7 days C: 8-30 days D: Over o ne month E : Over one year O Alcohol O Marijuana O Crack Cocaine O Cocaine O T obacco O Ecstasy O Crystal Met h. O Heroin O Talwin & Ritalin O An tidep ressa nts O Prescrip tion Drugs O Hallucinogens O Morphine O Inhalants Othe r: Whi ch is you r d rug of choice?
4 What is your p attern of use: O Daily O Weekly O Binges O Ot her: Which of the followi ng areas have been neg ativel y affected by your us e? O School Att endance O Family Relationships O Physical Health O Employment O Psychological Health O Le gal Situation O Oth er: Is the re any history of alcohol /drug use in yo ur fa mily of origin? O Yes O No If ye s, please explain: Do you have any of th e f ollowing Pr ocess Addictions? O Gamb ling O Relationship[s] O Sh opping O Wo rkaholic O Sex O Other Are you now, or h ave you ever been an I V user ? O Yes O No As o f to day, wh en wa s yo ur last use of any alc oho l/drug?
5 Wh at Type? How much? 4 C. Social Profile Have you attended TREATMENT prev iousl y? O Yes O No If yes, please explain: Year Dates Name of Centre & Location Completed? Drug[s] treated for O Yes O No O Yes O No O Yes O No In what way is your dr inking or dru g use a prob lem for you? What is the longest peri od you have been able to stay free of s ubst ance s? What enab led you to re main free of substances at that time? Wh y are yo u see king treat ment at this ti me? O To get ch ildr en back O Co urt orde red O Cond ition of employment O Fami ly pre ssure O Ot her: please explain: Do you have cu stody of any minor ch ildren?
6 O Yes O No What are the plans for yo ur children while you are in TREATMENT ? What are yo ur expectations of the TREATMENT PROGRAM ? List any pr oblems or concerns yo u may ha ve that could aff ect your TREATMENT ? 5 Social Profile Cont. Wha t are you r behaviour pa ttern s when you drin k and/o r us e drugs? O Aggressive O Argumentati ve O Le ss Shy O Qu iet O Outgoing O With dr awn O Othe r, p lea se explain: Have you ev er been refused TREATMENT or t erminated from treat ment? O Yes O No If ye s, please explain: Did yo u or any member of your fa mily attend residential school? O Yes O No Please provide details: Are you presentl y invo lve d w ith any other agenc ies [ Social Services, Probatio n Serv ices, NNADA P, Outp atient Cou nselling, etc.]
7 ], th at m ay pr ovide continu ed s uppo rt to you when you ha ve comp leted trea tment? If ye s, please list agen cie s? O Yes O No May we involve these agen cies in yo ur case planning? O Yes O No If ye s, please provide contact infor mation: Agency Contact name Phone Number 6 D. Legal History Have you ev er been convicted of a crime? O Yes O No What was the out come? O In carce rated O Cond itional Se nt ence O Monitor O Pr obati on O Bail O Te mporary abs ence O Ot her: Were you under the i nflu ence of a ny su bstance[s] at the time of your off ence? O Yes O No If ye s, please explain: Do you have an y charges pend ing or b efo re the c ourt at thi s time?
8 O Yes O No If ye s, what are the charges: When and wher e is you r next court appear ance ? Wh at is your prese nt le gal status ? O Paro le O Pro bation O Bail O TA O N/A Note: You may be required to submit a fo rmal list of past convictions prior to Cree Nations TREATMENT Haven acceptance. E. Medical History Do you have any medi cal hi story o f seizures, allergies, h eart conditions, or diab ete s? O Yes O No If y es, e xpl ain: Have you ev er had any suicidal atte mpt or ideations? O Yes O No If ye s, please explain: Have you ev er und ergone a M ental Health A ssessment?
9 O Yes O No If yes, would y ou be willing to sh are a copy o f t he assessment with our center? O Ye s O No If yes, who pro vided the asse ssm ent and when? If female, are you c urre ntly pregnant? O Ye s O No Due date: Have you used any alcohol or drugs dur ing your pregnanc y? O Yes O No Are th ere any other medical concerns we should be a ware of? If yes, pl ease explain: 7 F. Referral Agent Questionnaire Name: Title: Agency: Addr ess: Ph one: How long ha ve yo u be en in vol ved with this clien t?
10 In yo ur opinion, wh at is mot ivatin g t his client to seek TREATMENT ? Describ e in det ail t he mo st impo rta nt areas fo r t he ap plicant to address in tr eatment? O Abandonment O Anger O Gr ieving O Sex ual a buse O Parenting s kills O Rejection O Resi den tial Scho ol O Other: Are you aware o f a ny factors in th is client s li fe [medical/legal] t hat may pose a t hreat to other clie nts in treat ment? O Yes O No If yes, please explain: Has th is client been referred to and denied TREATMENT at any oth er ce nte r? O Yes O No If yes, p lease explain: Will you continue to see the clie nt on ce h e/s he h as c omp leted treat ment?
