|
Welcome to Wilp Si’Satxw Community
Healing Centre. Together we can make a difference in delivering
quality service to clients who are seeking help for their addictions
and collateral issues.
PHILOSOPHY
Wilp Si’Satxw believes that people who are addicted to
spirit destroying chemicals can gain power over their addictions. It
is with this belief that the primary purpose of Wilp
Si’Satxw is to provide a holistic,
spiritually-based Healing Centre where people can go through the
processes that will start them on the road to recovery. This approach
looks at the following realms within an individual as important to
the healing journey
Spiritual
Emotional Physical,
Sexual Mental
Each person
has the ability to confront problem issues and secure their personal
power to walk in health and wellness. Each of you are
responsible for yourselves and your self
healing is a personal choice.
OUR GOALS
INCLUDE: providing
information concerning:
·
Alcohol and Drug
Abuse
Communication
·
Traditional Native
Values
A.A./N.A. Program
·
Treating Healthy Relationships Grief/Losses
·
Self Awareness/Self
Care
Spirituality
·
Relaxation, Meditation
TREATMENT
PROGRAM SPECIFICS
·
Individual and Group Counseling Sessions.
·
Individualized treatment plans based on client goals.
·
Educational teachings on all aspects of addictions and related behaviors.
·
Development of First Nations spirituality and cultural awareness
through the use of traditional teachings and
Ceremonies.
·
Physical fitness promotions through nutrition education and regularly
scheduled recreational activities.
·
Confidential HIV/AIDS surveillance program (on a voluntary basis).
·
Psychological and other professional services.
PROGRAM
ACTIVITIES AND RESOURCES:
·
First Nation Elders Smudge
Ceremonies Sweat Lodge
·
Alcoholics/Narcotics Anonymous Program and Meetings
The
culturally-based, 14, 27, 34 and 41 day treatment programs assist the participants in learning to use First
Nation culture and spirituality as a major tool to maintain sobriety.
Out of respect for all belief systems, the spirituality components of
the program will not interfere, but will enhance present spiritual
beliefs.
WHO CAN
COME?
Applications
are accepted by referral from any of the following sources:
·
Alcohol & Drug Counselors
Band Social Workers
·
NNADAP
Workers
All Referral Workers
·
CHR’s
Any Treatment or Recovery Centre
All
Assessment & Referral packages are filled out with the client and
returned to Wilp Si’Satxw
Community Healing Centre. The COMPLETE application, including
pre-admission medical exam, and T.B. test, (only if T.B. test is
positive then a Chest X-Ray is required) must be submitted before
booking a treatment date. Clients will be booked as we receive their
referral package and medical examinations by mail or by fax. Travel
(return) arrangements must be confirmed prior to entry into the
programs offered by Wilp Si’Satxw.
Pre-treatment
alcohol/drug Counseling and after-care
planning is an important part of the application and referral
process.
Any person
on parole, probation and court order: referral worker must send a
copy of that order to Wilp Si’Satxw
Community Healing Centre.
While at Wilp Si’Satxw Community
Healing Centre clients must be free of all outside appointments,
(court, probation, lawyers, doctors, dentists, specialists, etc.).
Should a client arrive and request to be excused from the program for
a previously booked appointment, they may be discharged from the
program.
Client will
be given a copy of the House Rules, to review and discussed to ensure
that he/she understands the house rules.
One week
prior to intake day, if in receipt of all forms the referring agent
and/or the client will be contacted for confirmation.
In order to
accommodate this process we are requesting that our referral workers
advise clients that on intake day, the Centre is open at 8:00 a.m.
Buses for the East & West are met on that day for clients
arriving by bus. If there is no other alternative but to send the
client earlier than on intake day, for the safety of the client
please contact the intake clerk to ensure that arrangements can be
made to accommodate the client.
PROGRAM
PROFILES
Two Week
Refresher:
This intake
is for clientele who have been through a treatment program. The
program revisits their personal "Wellness Wheel", what they
have been doing to maintain clean from alcohol and drugs and to
discover new tools to continue with a good healing journey.
"Reclaiming
Our Spirit" (two five week Indian Residential School program)
This five
week program focuses on the impacts of Indian residential school, how
it affects the lives of the survivors, their children, the community,
and the nation. They are taught the importance of being alcohol
and drug free. Good healing tools are learned for working
through their personal Indian residential school issues.
Four Week
Family Program (2 programs)
This program
is for families who need family treatment. Couples are allowed
to attend. The centre has Early Childhood graduates to take
care of the children, babies, and toddlers up to eight years
old. Children 9 and up join the parents in the circle room
workshops. The young people learn the difficulties of today's
parents and the parents, the difficulties of being a young person
today. Learning to respect each other in a family setting.
Six Week
Co-ed Program (2 Programs)
This program
focuses on dysfunctional lifestyles, the root causes and how it affects
the individual, family and nation. Throughout the program,
clients are identifying their own personal problems from the
workshops presented. The importance of becoming clean and sober
and tools to maintain their sobriety and start a good healing journey.
Four Week
Men's Trauma Program
This program
is for men that are uncomfortable with a Co-ed program. It
deals with the root cause(s) of men's issues and
how it affects the
individual, family, and nation. The importance of becoming
clean and sober, and tools to maintain their sobriety
Four Week
Women's Trauma Program
This program
is for women that are uncomfortable with a Co-ed program. It
deals with the root cause(s) of women's issues and
how it affects the individual, family, and nation.
The importance of becoming clean and sober, and tools to maintain
their sobriety
Four Week
Domestic Violence and Suicide Awareness
The program
is co-ed and focuses on each participant's involvement in domestic
violence. It identifies the root cause(s) of anger and abuse
and how the good emotion of anger can be dealt with and redirected in
a good way. The program shows how anger and abuse affects the
individual, family, and community. The importance of becoming
clean and sober, and tools to maintain their sobriety and begin a
good healing journey.
*All intakes
are alcohol & drug treatment based with specialty focuses, and
cultural teachings. Every program has an Indian residential
school awareness presentation revealing the impacts of these schools
as a source of misery in Native communities.
·
PLEASE NOTE THAT WITH EVERY INTAKE
THAT ACCORDING TO POLICY, THERE ARE ONLY TWO LEGAL APPLICANTS ALLOWED
PER SESSION.
Outreach
Counselors will travel to your community.
For further information please mail, fax your inquiries or request
to:
Vernon
Smith, Executive Director
Our
toll-free number: 1877-849-5211
Fax
No: (250) 849-5374
·
Anger
Management
Intimacy/Relationships
·
Co-dependency Dealing
with Family pain
·
Self
Esteem Residential
School Issues
·
Healing
Circles Communication
Skills
·
Loss &
Grieving
Stress Management
·
Medicine
Wheel/Culture
Family Violence
There are
also workshops, training and healing sessions geared to all age
groups.
Sexual Abuse
and Suicide Workshops are only available outside the Centre if there
is a support system in place for those who disclose ie. Counselor, group
support, etc.
Also offered
at our Centre:
·
Sweat Lodge
Ceremonies
Smudge Ceremonies
·
First Nations
Elders
Alcoholics/Narcotics Anonymous Program and meetings
·
Orientation & Tour of the Centre - phone for appointment
Wilp Participants Please Bring:
·
Comfortable clothing for: Weather, swimming, sweats, and exercises
·
Personal Hygiene items: Shampoo, face soap, shaving items,
toothbrush/paste, etc.,
·
Enough Medication for the duration of the program
·
Writing materials: Paper, stamps
·
Phone/Calling Cards
·
Laundry items: Laundry Soap Cubes, Bounce, etc.,
·
We do provide towels but you are welcome to bring your own.
*Please note
that Wilp Si’Satxw
is in the progress of an expansion process and will accept any
donations mailed to the above address and attention to: Wilp Si’Satxw House of
Purification Society. Wilp Si’Satxw is a member of the registered charities
act and our charities number is: 119299279RR0001.
Acknowledgement will be made to all parties that donate.
WILP
SI;SATXW COMMUNITY HEALING CENTRE
Box
429, Kitwanga, B.C. V0J 2A0 PH:
250-849-5211or 1-877-849-5211
Email:
v.smith@xplornet.com
Website: www.wilpchc.ca
FAX:
250-849-5374
NATIONAL NATIVE ALCOHOL AND
DRUG
ABUSE PROGRAM
REFERRAL & ASSESSMENT PACKAGE
REFERRAL
WORKER:
________________________________________________
ADDRESS: __________________________________________________________
____________________________________________________________________
PHONE:
(_______)____________________________________________________
Fax:
(_______)_______________________________________________________
INTAKE DATE:_______________________________________________________
QUESTIONS FOR REFERRAL AGENTS
1.
Are they attending regular Counseling
sessions with you? _____Yes ____No
If no, please explain ______________________________________________________
______________________________________________________________________
We require that the client
have 6 Counseling sessions prior to coming
in for treatment.
2.
Are they detoxed?
____Yes _____No
We require that they be detoxed at least 1 week prior to coming in for
treatment.
3.
Is it mandatory that he/she come in for
treatment?
____Yes
____No
We have an open program, where the
participant may leave is he/she feels that they are not ready for
treatment. Healing is something that can only take place when the
client is willing to change.
4.
Is he/she Native?
____Yes _____No
Does he/she live one reserve?
____Yes
____No
If “yes” then fill out the
subsidy form and send it in to Health Canada. If “no” then please
indicate who will be paying for the treatment.
__________________________________
5.
Is his/her return travel arrangements
made?
____Yes _____NO
6.
Is his/her return travel arrangements made?
____Yes _____No
Comments:
_____________________________________________________________
7.
If travel arrangements are not made, please explain why?
_______________________________________________________________________
8. Should your client not make
it into this program, would they like their package forwarded into
the next program?
Yes No
v PLEASE
NOTE THAT IF THIS SECTION IS NOT COMPLETED THE CLIENT WITLL NOT BE
FORWARDED INTO THE NEXT PROGRAM.
Please be sure to go through the
Referral Package with them so that they fully
understand the program and its requirements.
We discourage booking of a
client with us, if they are booked at another TREATMENT CENTRE
for the same time period. We run into problems when there are
numerous cancellations, and in all fairness it gives other potential
clients who are willing to come into the program a chance to make it
in.
SOME VITAL POINTS TO MAKE
OUT:
a) Is he/she up
for any appointments in the duration of their stay at Wilp? We request that there be no
appointments.
b)
Advise the clients of the harmful effects of over-the-counter drugs
such as: Tylenol 3’s with codeine, also ensure that they do not have
the drugs on them, upon entrance into the program.
Items not to include: alcohol
based mouthwash, after shave lotion, non-prescription drugs, clock,
radios, walkmans, ghetto blasters, weapons & junk food.
Clients should be made
aware that a luggage check will take place upon arrival.
The primary purpose of this
assessment package is for client referral to Wilp
Si’Satxw Community Healing Centre. The
assessment package may also be used for referring a client to another
type of agency other than a Treatment Centre
as it is consistent with the information collected for other National
Native Alcohol & Drug Abuse Program funded treatment centre.
CONTENTS
I.
PERSONAL INFORMATION - basic client information for intake at Wilp Si’Satxw
……………………………………………………………………………………..pg.
7
II.
CLIENT HISTORY - an overview of the client’s past and present
situation.
………..………………………………………………………….................pg.
8, 9, 10
III.
CONTACT ASSESSMENT - an assessment of the client’s presenting
problem(s)
...............................................................................................................................pg.
10
IV.
CONSENT FOR TREATMENT - client
consent to be treated.
...............................................................................................................................pg.
11
V. CONSENT
FOR RELEASE OF INFORMATION - client consent to allow the package
of information to be sent to Wilp Si’Satxw.
...............................................................................................................................pg.
12
VI.
PRE-ADMISSION MEDICAL EVALUATION - an evaluation of the
client’s health. The top part of the first page is to be filled out
by the client and worker; subsequent pages are filled out by the
client’s doctor.
.........................................................................................................................pg.
13, 14
VII.
HOUSE RULES - this form must be filled out and sent back (pg. 17 only) with the referral package.
..................................................................................................................pg.
15,16,
17
VIII
Legal Papers – (if
applicable) Any documentation pertaining to charges, court order,
probation order, etc. must be forwarded to the Intake Clerk before
acceptance into Wilp Si’Satxw
program
Surname:
___________________________ Given Name:________________________
Address: __________________
City:__________________ Postal Code: ___________
Phone: (____)_____________
Birth Date: ____Day ___Month ____ Year
Sex:
Male
Female Care Card Number:
________________________________
Status Indian
Yes No Band Name
&No:____________________________________
Living on Reserve
Yes
No Native Language
Spoken Yes No
Marital Status:
____Single
____Married
____Common-law
____Separated
____Divorced ____ Widowed
Family Type:
____Living Alone
____Living
with Spouse
____Living with
Parents ____Single
Parent
____Living with
Friends ____with
Spouse & Children
____with Extended Family
(Specify who) ____________________________
____Other (Specify
who)_________________________________________
Next of Kin:____________________________
Relationship:__________________________
Address:
_____________________________ Telephone: (____)______________________
Did client attend Indian Day
School?
____Yes ____No
Did client attend
Residential/Board School?
____Yes ____No
Did client’s parents attend
Residential School?
____Yes ____No
Did client’s grand-parents
attend Residential School?
____Yes ____No
Highest Level of
Education: ____No Education
____Primary
____Junior High
____Adult
Ed.
____Secondary ____Comm.
College ____Trade
School
____University
Income Source:
____Job Usual Occupation:
___________________________________
____Income
Assistance
____UIC
____Family
____Pension ____None
____Interest ____Other
Legal Status: (Present
Involvement)
____Not
Applicable
____Bail
____Probation
____Parole ____Temporary Absence
Referral Source: (Please Check)
____Self
____AA/NA ____Band Social
Worker ____CHR/NNADAP Worker
____Police
____Court
_____Parole
_____Employer
____Family _____Halfway House
____Residential Treatment
Centre ____Hospital
_____Detox Unit
____Native Court Worker ____NNADAP Projects Outpatient
Clinic ____Other Outpatient
Clinic ____Other_____________
Presenting Problems:
____Co-Dependency ____Relapse
Prevention _____Sexual Abuse Victim
____Family Domestic
Violence _____Residential School
Have you ever used intravenous
(IV) Drugs?
____Yes ____No
Substance Abused:
____Alcohol ____Hallucinogens
_____Narcotics ____Prescription
Drugs
____Solvents
____Non-Prescription Drugs
Were you in Treatment Centre within
the last two (2) years?
____Yes _____No
____Haisla _____Nenquayni ____Hey-way-Noque ____Kakawis
____Nimpkish ____Round Lake
____Wilp Si’Satxw
____Tsow-Tun Le Lum
____Other Native Centre Outside
B.C. ____Other Non-Native Centre
Chemical Dependency
1.
History of past and current substance use
|
SUBSTANCE
|
AVERAGE/AMOUNT/DAY
|
LENGTH OF TIME
USED/ DURATION
|
|
Alcohol
|
|
|
|
Street Drugs
|
|
|
|
Prescription Drugs
|
|
|
|
Other
|
|
|
2.
Abuse pattern: (usual pattern)
Daily_____________
Binge___________________
3.
Reaction to abuse: indicate all effects of experience
____Hangovers ____Shakes ____Seizures
____DT’s
____Ulcers _____Cirrhosis
____Heart
Problems ____Blackouts
____Behavioral
changes/problems ____Withdrawals
____Tolerance
level ____Pre-occupation with
use ____Use upon waking (eye opener)
____Attempts to control use
Other
_________________________________________________________________________
CO-DEPENDENCY
1. Problem/positive
signs and symptoms of co-dependency exhibited.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
2.
Effects of other’s substance use/abuse on client (i.e.
violence, money problems, housing
problems, psychological problems).
__________________________________________________________________________________________________
__________________________________________________________________________________________________
NUTRITIONAL NEEDS
1.
Are you comfortable with your
weight?
____Yes _____No
2.
Have you ever taken drugs to
control your weight?
_____Yes _____No
3.
Do you have a history of anorexia
or bulimia?
_____Yes _____No
4.
Is a special diet required? If yes, give
details________________________________
MEDICAL/PSYCHOLOGICAL FACTORS
1. Significant past and
present medical issues (ie. Cancer,
diabetes, impairment hearing loss, loss of
limbs)_______________________________________________________________________________________
Significant past and present
psychological issues
_________________________________________________________
_________________________________________________________________________________________________
SOCIAL SITUATION/HISTORY
PERSONAL
1.
Was client raised by natural
parents?
_____Yes _____No
2. Was
there alcohol or drug problems in the family of origin while client
was growing up (ie.
Parents, guardian, sibling)?
If yes, give details
3. Major
areas affected by the dependency (such as leisure time, friends,
relationships with children). Give
details.__________________________________________________________________________________
4. Has
there been a death in the family due to substance abuse?
____Yes ____No
5. Have
children ever been in foster care or
apprehended? ____Yes
____ No
6.
Children: How Many? _____ Status (indicate whether they are)
____At home _____In
Care _____Apprehended
7.
LITERACY SKILLS: Is client able to read and/or write on own?
____Yes ____No
If no, please explain
_____________________________________________________________________________
______________________________________________________________________________________________
SOCIAL/SUPPORT
1. Indicate client’s potential
support network, ie. Family, friends,
religious organizations, healers, cultural organizations,
self-help groups.
______________________________________________________________________________
_______________________________________________________________________________________________
2.
Where does client actually go for support? _______________________________________________________
_______________________________________________________________________________________________
LEGAL
1. Does
client have any prison convictions or a criminal record? If yes,
indicate whether alcohol or drugs involved.____________________________________________________________________________________
2. Are
there any current: ____Outstanding Warrants
____Charges ____Court Case
____Parole
____Probation ____Incarcerated
2.
Name and phone number of Probation/Parole Officer:
_________________________________________________
__________________________________________________________________________________________________
NOTE: COPIES OF ALL
DOCUMENTATION PERTAINING TO THE ABOVE MENTIONED MUST BE INCLUDED
PRIOR TO CONFIRMATION OF ACCEPTANCE.
MARTIAL
1.
How long has client been involved in present marital situation?________________________________________
__________________________________________________________________________________________________
2.
Indicate the strengths holding the situation together and the
weaknesses that could cause or are causing problems.
Marital Strengths?
__________________________________________________________________________________
__________________________________________________________________________________________________
Marital Weaknesses?
________________________________________________________________________________
___________________________________________________________________________________________________
3.
Relationship Breakdown? ie. Drugs, alcohol, violence, etc
_____________________________________________
___________________________________________________________________________________________________
SPIRITUAL/CULTURAL
1.
Is client involved with spiritual practices, smudging, sweat lodge
ceremonies, cultural events, native healers,
self-healing practices. Give
details._______________________________________________________________
___________________________________________________________________________________________________
2.
Is client willing to participate in spiritual/cultural
events ____Yes
____No ____Maybe
If no, please explain
__________________________________________________________________________________
1.
What event(s) took place that caused the client to seek help at this time?
Include details surrounding the event(s).
_______________________________________________________________________________________
_______________________________________________________________________________________
CLIENT’S
PERSPECTIVE/PERCEPTION OF PROBLEM
1.
Does client feel he/she has a chemical/co-dependency
problem? ____Yes
_____ No
_______________________________________________________________________________________
2.
Does client express a need to change his/her life
situation?
____Yes
____No
3.
Are native culture and values significant for client’s
change?
____Yes ____No
SPECIAL NEEDS
1.
Special needs bearing on initiation of case plan (ie.
Disabilities, FAS/FAE, illiteracy)
_______________________________________________________________________________________
REFERRAL
1.
Is client in a therapeutic relationship with the referral
person?
____Yes
____No
2.
Will referral person be doing follow up after program completion?
____ Yes ____No
I,
________________________________________ (name of client), agree to
enter the:
Wilp Si’Satxw Community
Healing Centre, P.O. Box 429, Kitwanga,
B.C. V0J 2A0 for the
purpose of treating my alcohol/drug dependency
problem.
I understand for the client and
staff to work effectively, the treatment program will include:
Counseling Assessments
Spiritual, physical and
psychological development
Group therapy sessions/talking
circles
Contact with referral sources
Maintenance of confidential
client records as stated in the Alcohol and Drug Commission Act
Of British Columbia.
I understand that if I need
medical attention, I will be attended to by the proper personnel
and/or
Transferred to an appropriate
facility.
I understand that treatment is a
continuum. Therefore, I agree to be involved with aftercare.
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 Wilp Si’Satxw.
Comments:
______________________________________________________________________________________
Date: __________________________________________________
Signature:_______________________________________________
Parent or Guardian (if
applicable) ______________________________
Phone Number (_____)
_____________________________________
Witness: _________________________________________________
Date:____________________________________________________
- CONSENT
FOR RELEASE OF INFORMATION
|
|
This section is to be filled out
if referral is made and client information is required.
Client Name:
_______________________________________
Date of Birth: ________Day
_________Month ________ Year
I,
________________________________________ (Client’s Name), hereby give
my
permission for Wilp Si’Satxw Society
Community Healing Centre, P.O. Box 429, Kitwanga,
B.C. V0J 2A0
To contact (name and address of
agency providing information)
Name:
_____________________________________________
Address:
___________________________________________
For information to be released,
limited to describe type(s) of information to be released.
______________________________________________________________________
I understand that no other
information will be released to any other persons without my written
consent unless these persons
have a court order or are concerned with medical treatment in
an emergency situation. I also understand that
I can withdraw or amend my consent to the release/request of
information at any time.
All information is Confidential,
in accordance with relevant statutes.
Start Date of Consent:
_________________________________
End Date of Consent:
__________________________________
In order for this release to be
valid, it must be completed in its entirety.
Client’s Signature:
________________________________________
Witness:
________________________________________________
(may be referring person or assessor)
VII. PRE-ADMISSION
MEDICAL EVALUATION
|
|
Date:
_______________________________
Client’s
Name:_______________________ Medical
#___________________________
Date:
______________________________
Referral
Agency:_____________________
Address:
___________________________
CLIENT RELEASE
I, ____________________________,
hereby request and permit my physician to release
medical facts and assessment
about me to _____________________________and
Wilp Si’Satxw Society. The
photocopy of my signature on this form is as valid as the original.
Client’s
Signature:__________________________________
TO THE PHYSICIAN
The above named client is to be
medically assessed as a potential participant in our five week\
residential life-skills program. Our program is designed
to help people who acknowledge that
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.
MEDICAL EXAMINATION
Name:
__________________________________
1.
Date of last alcohol use:
____________________________________________
2.
Date of last psychoactive drug use:
___________________________________
3.
Current Diagnosis: ________________________________________________
Current
Medication(s)_______________________________________________
4.
Medical problems to be followed while in treatment(MD is available
for follow up) ______________________________________________________________________
5.
Any Allergies? ___________________ If so, what?
_______________________
6.
If female, date of
L.M.P.____________ Is
patient pregnant?
Yes No
7.
Date of latest chest x-ray, if known, and result. (Please not, if last Chest x-ray more than
six months ago, it is mandatory
for client to have had a chest x-ray before coming to treatment if
T.B. test is positive.
___________________________________________
8.
Functional inquiry – is there any disorder of the following?
Hair, skin, nails(especially
current to recent infestations or infections
Yes No
Ear, nose, throat
………………………………………………...
Yes No
Muscular-skeletal
system………………………………………. Yes
No
Blood, Lymphatic system……………………………………….
Yes No
Cardio-vascular
system…………………………………………
Yes No
Respiratory
system………………………………………………
Yes No
GI
system…………………………………………………………
Yes No
GU
system………………………………………………………..
Yes No
CNS – especially HX of
seizures………………………………
Yes No
Past History of
TB………………………………………………..
Yes No
9.
Family
History
Alcohol/drug
problem……………………………………………
Yes No
Psychiatric
history……………………………………………….
Yes No
Adopted…………………………………………………………...
Yes No
10.
Physical Examination
Height:_______________
Weight: ______________ BP/PR:_______________
|
|
NORMAL
|
ABNORMAL
|
|
Appearance
|
|
|
|
ENT
|
|
|
|
Hair, Skin, nails
|
|
|
|
Muscular-skeletal
system
|
|
|
|
Thyroid
|
|
|
|
Cardio-vascular
system
|
|
|
|
Respiratory system
|
|
|
|
Abdomen
|
|
|
|
Central nervous
system
|
|
|
|
Evidence of
sexually transmitted disease
|
|
|
11. Please
comment on any abnormalities noted above.
____________________________
12.
Have you any comments, suggestions or insights that might be helpful
in terms of client’s
being physically and mentally able to participate in group, one-to
–one counseling and living
in residence for five weeks?
______________________________
AS PER PRE-REQUISITE TO
TREATMENT YOUR PATIENT MUST:
1.
Be free from all communicable disease ie.
STD, Scabies,
lice
Yes No
2.
Have a negative T.B. Test in the last 6 months: Pos. ____
Neg.____ Date: _________
3.
Be clean and sober from Alcohol and all Psychoactive
medications/drugs (all mood or mind
altering substances) for a
minimum of 14
days
Yes No
Date of last use:
Alcohol:___________________ Drugs:_________________________
A copy of recent lab work, if
available, would be appreciated eg. CBC,
liver function, FBS etc….
I have examined this client and
find him/her to be fit to attend treatment.
Physician’s Signature:
________________________________________
Address:
______________________________ Date: _______________________
Telephone No: (____)
____________________ Fax No: (____)_______________
NOTE: PLEASE PRINT CLEARLY
*CLEAR EVIDENCE OF H1N1 AND
FLU VACCINATIONS ARE REQUIRED BEFORE ACCEPTANCE INTO WILP SI'SATXW
COMMUNITY HEALING CENTRE
Please give a copy of the
house rules to the client so that they are fully prepared for
the Wilp
Si’Satxw Program
These guidelines are provided to
create a healthy, safe, positive environment for your program. Please
read them and be prepared to follow them for the
welfare of all.
Failure to follow these
guidelines may result in:
-
Loss of privileges (eg. Phone privilege or
Sunday pass)
-
Written warnings
-
Dismissal
The severity of the incident may
justify immediate dismissal.
ALL STAFF MEMBERS HAVE THE
AUTHORITY TO ISSUE INCIDENT REPORTS AND TO
DISMISS CLIENTS.
………………………………………………………………………………………………
ALCOHOL AND DRUGS
v The use or
suspected use of alcohol or drugs throughout the program is grounds
for discharge.
v Luggage will
be inspected upon arrival. If suspected under the influence of
alcohol or drugs clients
may be subject to room checks during their
stay. Incoming parcels will be examined with a Staff
member present.
v All
medication, prescription and non-prescription drugs to be turned in
upon arrival.
HEALTH AND SAFETY
v Smoking is not
allowed in the buildings.
v Food and drink
must be kept in the Dining area only.
v Residents are
required to keep themselves clean, regular bathing is required.
Please do laundry
after sessions and before 10 p.m. See
housekeeper for soap and supplies before 5:45 p.m.
v Please remain
in the bed that you are designated to.
v
Bedrooms are not to be locked at any time (Fire regulations)
v
In case of FIRE ALARM quickly conduct yourself to the gathering point
(Do not take this lightly)
v Beds need to
be made and rooms cleaned each morning. We also ask that you
cooperate in doing
your assigned daily chores.
v No horseplay.
v Chewing gum,
pop and other junk food are not allowed on the premises or on
outings.
v
All walkman’s, radios, clock radios, tape recorders, cassette tapes,
C.D.’s and vehicle keys must
be turned in upon arrival.
TELEPHONE
There will be no outside contact
during the first week of the program so that clients can develop a
bond within the healing community. This will include phone calls,
mail and messages.
v On
the 7th day the telephone will be available for residents to make
personal call from
4:00 – 5:00 p.m.
5:30 – 7:00 p.m.
9:00 – 10:00 p.m.
depending upon completion of chores. Calls are
only allowed every second day.
v Outgoing calls
are to be made on the pay phone only. Mail and messages will be
delivered by
your counselor.
v No calls may be made
during session, evening included.
v The time limit for
calls is 15 minutes per call with respect to others. The length of
calls will be monitored. Please make sure your calls are completed
within your time slot, if not, your phone privileges could be
withheld.
v Phone cards can be
purchased at the office. Please make sure you have purchased the
phone
cards before 4:00 pm on Fridays for your weekend
calls. Office is closed on weekends.
WEEKENDS
v All residents are to
remain on the grounds area unless on a pass. Clients must sign out
when
leaving the residence and sign in when returning to
the residence.
v Depending
upon conduct and participation, a pass may be granted on the second
Sunday from
9 am to 9 pm.
v All passes
must be approved by a counselor before
leaving the grounds. If there are changes to
the pass destination, approval must be given ahead
of time.
v After the
second week visiting hours are from 1 – 5 pm on Sundays Only.
v Visiting is
confined to the Dining or Lounge area only. (Not bedroom areas)
Sexual contact in
residence is prohibited.
v
Visitors under the influence of, or suspected of being under the
influence of alcohol and other
drugs are prohibited
OFFICE
v To see counselor or Office Manager please use the front
door. The administration building is off
limits except for one-on-one sessions with your counselor.
v OFFICE
IN RESIDENCE IS STRICTLY OFF LIMITS (except to take medication
with assistance
of Attendant, or if you are dealing with a
personal issue). The office phone is not to be used at all.
Music is to be turned on by
staff only.
OTHER
v Please do not
lie down on or put feet up on chesterfields in the day lounge. Also
no food or drinks
are allowed in this area.
v Physical or
verbal abuse towards staff and other clients is totally unacceptable.
v Please refrain
from the use of profanity or other inappropriate language.
v Sexual contact
between clients, and between clients and staff is prohibited eg. Kissing,
inappropriate hugging/touching.
v Residents are
responsible for all personal belongings and effects. All valuables,
Bus tickets, and
money in excess of $20 will be put away for safe
keeping. These items will be returned upon
request. Wilp Si’Satxw accepts no responsibility or liability
for personal belongings and effects of residents and visitors.
v Outside footwear
must be taken off and other footwear worn in all buildings.
v Caps are to be
removed in all buildings, T-shirts, hats or other items depicting
alcohol or any inappropriate message are not permitted. Dress
conservatively with respect to others.
v There are T.V.
monitors located in the residence building for the safety of the
clients and staff.
I,
___________________________________________ have read the house rules
and agree to comply with them for the duration of my stay. I
understand that these rules are set for my own well being and safety.
I realize that failing to comply with the house rules may interfere
with the safety and well being of others and I am subject to
disciplinary action as a result.
Client’s Signature ___________________________
Date: __________________
Witness by:
_________________________________
Date: __________________
NAME:___________________________________
D.O.B.___________________________________________
TRAVEL FORM
This form is
to be filled out by the person responsible for the return travel
costs for the client. Wilp Si'Satxw Community Healing Centre is a non-profit
organization and is unable to pay for travel costs.
I,
_______________________________________ (print name) agree to pay for
any and all travel costs incurred by ________________________________
(client's name). I understand that if the
client is discharged or voluntarily leaves treatment that Social
Assistance and First Nations and Inuit Health Branch will not cover
return travel.
In the case
that Wilp Si'Satxw
Community Healing Centre must pay for any of the client's travel, I
agree to reimburse Wilp Si'Satxw
Community Healing Centre for all costs incurred.
Signed:
____________________________________________
Date: __________________________________
Address:____________________________________________
Phone: _________________________________
City:
____________________________________________ Prov:______ Postal Code:
________________________
|
