1 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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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
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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Namgis Treatment Centre
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.
‘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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Namgis Treatment Centre
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
Fax: ___________________________________ Email: _______________________________ Name of A& D Counselor if different from the Referring Officer: ___________________________
Mary Hunt Namgis Treatment Centre Intake Coordinator
‘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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Namgis Treatment Centre
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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Namgis Treatment Centre
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
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.
‘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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Namgis Treatment Centre
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.