Referral Package

Referral Package
Contents:
Pages 2-3: Program Description
Pages 4-6: Client Information Package (to be given to client at time of referral)
Pages 7-15: Referral Form
Last revised: March 16, 2015
Referral Package Completion Checklist
Please note: This package is intended to be completed by a health care professional in collaboration with the client.
Before submitting this package to your local Health Authority for processing, please ensure the following tasks are
complete:
Complete the attached referral form.
Include the following collateral information if available and appropriate:
ƒ Current psychiatric and/or medical consult
ƒ Counsellor notes
ƒ Current MAR
In consultation with the client, complete and attach the Early Exit Transition Plan form and Participation
Agreement. Please ensure it is signed.
Attach current funding for the duration of the 90 day program including coverage for medications while in
treatment.
TB test (within the last 12 months) complete and attached
Reviewed resident guide with client (found at: www.heartwoodwomenscentre.ca)
The above components constitute a completed referral and will be reviewed by the Heartwood Admission Committee once
received from the Health Authority screening committee.
MSD Funding Verification Instructions:
1. Complete the top part of the form with the referral agent details, the client name and SIN#
2. Client must take the form to their ministry office who will complete it and fax back to the referral agent
3. Please send the completed form together with the referral application
4. For all other funding, please follow the instructions on the referral form
Referral Information Package
Heartwood, a residential treatment program, is a provincial tertiary 28 bed resource for women with substance use, mental
health concerns (including trauma) and primary health and/or chronic disease issues.
Program length: 90 days.
Inclusion criteria:
• Current substance use disorder
• BC females (including transgendered women) ages 19 and older
• Independence with activities of daily living
Not everyone with substance use requires residential treatment. Generally women who will be accessing this program have
substance dependence with other health concerns including mental health issues and physical health concerns. Community
based treatment services have not been effective or perhaps unavailable for this group of women. They may have had many
attempts at treatment across a wide range of services.
Heartwood’s goal is to provide a safe treatment environment for women to establish a solid foundation of recovery, stabilize
all health concerns and plan for ongoing supported recovery in the community following discharge.
Program: Heartwood is a comprehensive gender responsive treatment program which addresses women’s bio-psycho-social
spiritual needs. An interdisciplinary team including nurses, physicians, counsellors, social worker, recreational therapist,
dietitian, yoga therapist, expressive art therapist and acupuncturist collaborate with women to help them meet their treatment
goals.
The program is divided into two. The first is the S.T.A.R. program (stabilization, assessment and retreat). Women are in
S.T.A.R. for two weeks. This program assists the women to stabilize in their physical and mental health. Addiction medicine
and nursing assessments are completed during this time. Referrals for psychiatric assessments are also completed as
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required. Withdrawal management will be addressed and other treatments such as methadone, tobacco dependence
treatments, primary health care, nutritional interventions, acupuncture as well as group work will be provided.
The second phase is Treatment. During this phase women can expect to be involved in individual and group counselling
(with the emphasis on group), alternative therapies and recreation therapies. Treatment approaches are trauma-informed and
include but are not limited to cognitive behavioural therapy, motivational therapy, DBT, mindfulness based therapy, psychoeducation, skill development, pharmacotherapy, nutritional support, 12 step programs and peer support.
Treatment Planning: Heartwood empowers women to collaborate with their treatment team to develop a client-centred
treatment plan. This plan is reviewed throughout the program. The designated community case manager is contacted to
ensure continuity of care during the woman’s stay at Heartwood.
Transition Planning: Transition plans begin as soon as the women complete their stabilization. The social worker works with
women and their treatment team to determine a “best-fit” for aftercare ensuring a continuum of treatment whenever possible.
The Social Worker liaises with the case manager in the home community and collaborates on transition planning throughout
the women’s treatment.
A transition plan is established in case of an early exit from the program in order to ensure safety for the women returning to
her home community. In order to ensure a smooth transition it is recommended that the woman have a simple re-entry plan
upon referral. A more comprehensive transition plan is developed collaboratively throughout treatment with the woman, the
social worker and the support system in her home community.
Please review Heartwood’s exclusion criteria:
• Arson/fire setting
• Sexual activities involving minors
• Severe violence
Please contact Heartwood if your client has a history of severe violence and/or arson/fire setting, current self-harming and/or
eating disorder as these criteria can be discussed based on history and severity, but due to the location of Heartwood any
sexual activities involving minors will not be accepted.
If the client’s history with respect to these factors is not known to you, please investigate to the best of your ability.
If the client is admitted to Heartwood and it is subsequently found there is a current issue with respect to the factors above,
the client will be discharged and responsibility for the community care plan including housing will be the responsibility of the
referring Health Authority.
Physical violence, alcohol or drug use on premises or on outings with staff, drug dealing/sharing and/or recruitment
of other women into gangs or the sex trade will result in discharge from the program.
Additional Considerations: The following will also be considered when assessing clients for appropriateness for admission:
• Current client mix: to ensure a therapeutic environment for all clients, the client mix will be balanced with each
admission: i.e. Number of clients with high medical needs, number of clients with severe behavioural issues, number
of clients with unstable psychotic/affective disorders.
• Mental health and addiction team connection: clients must be connected to a mental health and/or addiction team for
continuity of care and discharge planning.
• Activities of daily living: clients must be independent in their activities of daily living including eating, toileting,
transferring and mobilizing.
Thank you for referring your client to our program. If you have further questions please call 604-875-2032 or check the
website www.heartwoodwomenscentre.ca.
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Client Information Package
The Heartwood Centre for Women is a community of staff and residents. The overall Heartwood Team includes many
professionals that are here to assist you in your recovery. You will have a treatment team who will help guide you through
your stay at Heartwood. The community is here to help and support you - we want you to succeed and will help you as much
as possible.
What we do: The Program will help you to:
• Identify your strengths and apply them to a long-term recovery plan;
• Improve your emotional, physical and mental well being;
• Understand the role drugs and alcohol have played in your life;
• Understand the role of mental wellness with substance use;
• Set realistic goals and learn how to live without depending on drugs and alcohol;
• Learn skills to improve the quality of your family and community relationships;
• Learn how proper nutrition can contribute to your recovery and overall wellness;
• Participate in regular fitness and leisure activities to support your recovery;
• Decrease your involvement with the law;
• Re-enter the community after treatment;
• Complete applications for services such as income assistance and housing.
The Program: Heartwood Centre for Women provides a full 12 weeks of treatment programming. The first 2 weeks begins
as the STAR Program.
S.T.A.R. (Stabilization, Assessment and Retreat): In order to focus on your program, you will be on retreat during this
time. You will be asked not to have contact with anyone outside of the program unless it is an emergency and organized
by staff. You will also not leave the program area without staff permission. The first one to two weeks of the program, you
will meet with the nurse, nurse practitioner, physician, and social worker. This is your treatment team and they will help
you set goals for your treatment.
The goals for this stage include managing withdrawal from substance use, identifying and treating medical and mental
health issues, developing stable daily routines, learning to live in a community, developing healthy sleep and hygiene
habits and learning to engage in structured programming.
If you smoke, on day one of S.T.A.R. you will be asked to abstain from tobacco use and be treated with a variety of
nicotine replacement therapies (as appropriate). You will be asked to begin to attend a smoking cessation group which
continues throughout your treatment.
The Acupuncturist at Heartwood works closely with clients to attend to physical and emotional health concerns through
the use of acupuncture techniques and various complementary therapies such as Energy Psychology, ie Emotional
Freedom Technique. Acupuncture can treat a wide range of health concerns, including, but not limited to headaches,
phobias, asthma, arthritis, addictions, menstrual cramps, lower back pain and carpal tunnel syndrome. Expressive Art
Therapy and Yoga also assist you to engage in the STAR program.
Treatment
Ten weeks of the Heartwood Program is dedicated to intensive treatment. Group programs address substance
dependency, trauma, mental and physical health issues. A team of professionals including physicians, nurses, nurse
practitioner, social worker, counsellors, recreation therapist and a dietitian work together to provide care for you. Other
specializations such as an acupuncturist, expressive art therapist and yoga instructor also provide regular sessions each
week to assist you in developing alternative methods of coping with symptoms and managing difficult feelings.
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A structured program supports your recovery journey by providing groups and activities focused on substance
dependency, trauma, women’s wellness issues, pain management, physician-led wellness groups, smoking cessation,
mindfulness practice, relapse prevention skills and emotional regulation skills.
During your program you will plan your treatment with your ‘team” by identifying your strengths, your personal vision of
recovery and goals which will lead you towards this vision.
Family Programming: The Heartwood Family Program is an information and education group for clients and the allimportant people who support them in their journeys to recovery. All clients attend and it is our hope that those whose
families are within travelling distance will encourage their loved ones to participate as often as they possibly can. This is a
valuable opportunity for clients and families to meet together in a respectful and supportive learning environment. This is
also a chance to come to a clearer understanding of how addiction has affected both client and family members /
significant others. Having attended the Family Program together, clients and their loved ones will also have a better
understanding of what to expect and how to support one another after treatment, as the journey of recovery continues.
Aboriginal Program: Aboriginal specific programming includes a weekly Talking Circle with an Elder, the opportunity to
attend sweats, use of smudging, and attending weekly family/pow wow nights at the Native Friendship Centre.
Important Information
• There is a two-week “retreat” period upon admission whereby you will be asked not to communicate with outside
family or supports. In the case of an emergency special consideration will be given through your primary counsellor
• All rooms are shared occupancy.
• Physical violence, alcohol or drug use on premises or while on outings with staff, drug dealing, sharing and/or
recruitment of other women into gangs or the sex trade will result in discharge from the program.
• Family visits are on Sunday from 1:00-6:30 pm.
• Family programming sessions are conducted on Sundays. Family programming attendance and participation is
mandatory for all clients
• Heartwood is a tobacco free environment and abstinence from tobacco is requested upon entry to the program
(Nicotine Replacement Therapy is provided). Smoking anywhere in the building will result in being discharged from
the program.
• Cell phones and cameras are not permitted for the duration of your stay.
• No personal lap tops or other devices will be allowed in the program.
• If you receive Income Assistance, you will receive only your comfort allowance while in the program. Please ensure
that you have made arrangements with your financial worker to cover your entire rent while in treatment.
• If you are not on income assistance please bring a small sum of money for outings.
• You are discouraged from bringing larger sums of money to the program or valuables. (Heartwood is not responsible
for valuables, personal lockers are in each room and locks are provided).
• Free laundry facilities are available
• All food and snacks are provided. Outside food is not permitted while in the program.
• Day Passes are scheduled with your treatment team as your treatment progresses and are not planned during the
S.T.A.R. program.
• Heartwood and the hospital within which we are located is a scent free environment. Any perfumes or scented
products will not be allowed in the building. Please bring with you shampoo, soap, deodorant, toothpaste which is as
scent free as possible.
• Please review the resident guide.
• Please only bring one suitcase and one shoulder bag with you as we have limited storage space.
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Directions and Map
Arriving By Car: Enter the parking lot at 29th and Heather Street. Proceed through the 4-way stop. Heartwood is on the
5th floor of building 77, the first building on the right. A staff member will meet you in the reception area.
Arriving By Bus: A taxi from the Vancouver bus depot will cost approximately $25.00. Tell the driver that you want to go
to the 29th and Heather entrance for the Women’s Health Centre. City busses stop at 29th and Oak but walking in with
luggage is difficult. Public transportation information and routes can be found at: http://tripplanning.translink.ca/.
Arriving From Airport: The easiest and quickest way to arrive here from Vancouver International Airport is by Taxi
which will cost approximately $30.00.
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Referral Form
Referral Criteria
A referral may be made by a Case Manager
A referral may be completed by another clinician in collaboration with the client’s Case Manager
Admission Criteria
Current substance use disorder
Female (including transgendered women) BC resident age 19 and older; and
Independence in activities of daily living.
Referral Information
Date of referral (day/month/year):
Client’s Legal Name:
Preferred Name(s):
Health Authority:
IHA
FHA
NHA
PHSA
VCHA
VIHA
Referring Practitioner:
Name of Organization:
Address:
City:
Province:
Telephone:
Fax:
Email:
Postal Code:
Ph:
Fax:
Physician Name :
Ph:
Fax:
Psychiatrist:
Ph:
Fax:
MH&A Case Manager:
Email Address:
Client Information
Female:
Transgendered: M/F
F/M
Date of Birth:
Age:
PHN:
Address:
City:
Province:
Telephone:
Email:
Marital Status:
Married
Common Law
Pregnant:
† Yes † No
Does the client have minor children?
Names
Postal Code:
Single
Divorced
Separated
Widowed
Pregnancy Due Date:
† Yes † No
Age
If under 19, what is the child’s current living situation?
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† Yes † No
Is client custodial parent?
If no, who has custody of child(ren)?
Please provide details, including contact information and MCFD contact information (if appropriate):
Telephone:
Fax:
Email:
Cultural Information
Do you identify yourself as an Aboriginal person that is First Nations, Metis or Inuit? † Yes † No
First Nations
Metis
Inuit
If you identify as an Aboriginal person are you:
Status
#:
Band:
Status: † Yes † No
Ethnicity:
First Language:
We invite you to let us know if there are any spiritual or religious practices or ceremonies that will support your wellness
while at Heartwood:
Emergency Designated Contact Person (Family/Friends)
Name:
Relationship:
Telephone:
Email:
Is there an identified Substitute Decision Maker (SDM)?
Name:
Telephone:
† Yes † No
Email:
Substance Use Treatment
Withdrawal management and treatment History (Please list all previous treatment and dates):
If no previous residential treatment history, is this due to lack of services available in community? † Yes † No
If no, please outline reason why treatment at a different facility has not been considered at this time:
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Please provide us with the client’s identified goals for treatment (please ensure this is provided by the client)
History Substance Use
Please fill this section out completely. Please put N/A next to the item if not applicable
Drug of choice
Primary
Date last used
# Days used
Typical amount
(list top 3)
or Route
(DD / MM / YY) in last 30 days
used daily
Age at
1st use
Stage of
change
Alcohol
Tobacco
Cannabis
Crack Cocaine
Cocaine
Heroin
Opioids
Benzo
Crystal Meth
Amphetamines
Hallucinogens
Inhalants
Other (Specify):
Gambling
Sexual activity
Pornography
Shopping
Do you have any history of disordered eating? † Yes † No
If yes, please define:
Binge Eating
Vomiting
Restricting
Laxatives
Excessive exercising
Have you ever participated in treatment for disordered eating? † Yes † No
When last active?
Is your disordered eating still active? † Yes † No
Other, please describe:
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Psychiatric History
Details:
Have these diagnosis been confirmed by a Psychiatrist?
† Yes † No
Please attach the most recent psychiatric assessment
Psychiatrist name: _______________________
Phone: ______________________________
Medical History
† HIV
Medical History (please describe):
History of seizures:
† Yes † No
† HCV
If yes, please detail
Last TB Test (Date): ___________________
Attach results with this form (Chest x-ray, Mantoux skin test)
Past Surgeries (Date):
Mobility Issues:
Details:
† Yes † No
Cognitive Impairment:
Details:
† Yes † No
Head Injury:
Details:
† Yes † No
FASD:
Details:
† Yes † No
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Current Medications: (please attach MAR if available)
Medication and dose
Medication and dose
Describe any challenges to participating in a group setting:
Education Level:
† Grade 9
† Completed high school
† Post-secondary
Safety Concerns
If yes to any below, please summarize and date most recent for each one
Suicide Ideation/Suicide attempts:
† Yes † No
Self harming behaviours:
† Yes † No
Overdoses:
† Yes † No
Aggression/anger:
† Yes † No
Current domestic violence:
† Yes † No
Risk taking behaviours:
† Yes † No
Housing
Independent Housing
Safe
Unsafe
Homeless
Post-discharge housing plan?
Type: ___________________________________________________
(e.g. house, apartment, shelter, SRO, etc.)
Where is client currently staying? (Please provide name of facility if possible)
Details: _________________________________________________
(e.g. shelter, friend’s home, parents, etc.)
Details:
Access to treatment services within community?
† Yes † No
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Legal
Does the client have a criminal record? † Yes † No
Details:
Is the client on probation? † Yes † No
Are there current charges pending? † Yes † No
Details:
Probation Officer’s contact name:
Phone:
Upcoming court dates: † Criminal † Family Date:_______________
(Please attach more information if needed):
Details:
Financial
Please provide details if applicable
CPP
Pension (other than CPP)
Disability benefits
Plan G
Extended Health
Income Assistance
Employer Extended Health Benefits
Other
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Funding Information
There is a per diem cost for Heartwood of $40 per day for 90 days for a total of $3600. There are several ways to receive
funding:
• If on Income assistance an application can be made to Ministry of Social Development (form attached). Please
ensure that client’s rent is covered while in treatment (maximum allowable is $375 per month)
• If a First Nations woman with status, the client can apply to Health Canada at First Nations and Inuit Health British
Columbia Region (Suite 540-757 West Hastings Street Vancouver BC V6C 3E6 Tel 604-666-9102 fax 604-666-3867)
or may be able to approach their band for funding
• Self pay. The client must provide a signed letter indicating that the client is prepared to pay the full amount. They are
also responsible for paying for all medications while in the program. Heartwood will provide the client with detailed
invoices documenting prescription costs.
• Extended benefits. Heartwood requires a letter from the client’s provider that accompanies this application.
• Clients may apply to their health authority through their Case Manager/Counsellor for accommodation fee subsidy for
partial or full payment
Treatment program will be paid (please check one box below):
Client/Family Paid – Please have the client submit a letter from the payee that is dated with the
payee signature, confirming they will pay for treatment and provide the following information:
Billed to name:
_____________________________________________
Billed to address:
_____________________________________________
Billed to phone:
_____________________________________________
Please note the Provincial Health Services Authority will bill directly for per diem costs each month.
MSD - Please complete the form on the next page.
Accommodation Fee – Please attach the relevant Health Authority Accommodation Fee Subsidy
Approval form.
Employer Paid – Please have the Benefits Administrator from the client’s employer call 604-8753754 to confirm treatment will be paid.
First Nations Health Authority - Please have a First Nations Health Authority Representative call 604875-3754 to confirm treatment will be paid.
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TO:
MINISTRY OF SOCIAL DEVELOPMENT - FUNDING VERIFICATION FORM
Residential Services: Heartwood Centre for Women
Ministry of Social Development
Office
Fax
Attn
Tel
Name
Position
Tel
Fax
FROM:
Client Name
SIN#
The above named client has been referred for admission to a qualifying residential addictions program, Heartwood
Centre for Women. Prior to admission, the facility requires confirmation that the client’s per diem costs (less and non
exempt income) will be paid by the MSD (Ministry of Social Development) while in receipt of, and eligible for, income
assistance.
Client Authorization
I ______________________, authorize the Ministry of Social Development to confirm my eligibility for funding, and to
release any related information to the above name staff.
Client Signature
Date
MINISTRY OF SOCIAL DEVELOPMENT – COMPLETE & FAX ABOVE
Client has an open and active file
… YES
… NO
Client has NOT applied for MSD within the last 30 days
… YES
… NO
Client funding eligibility
… ELIGIBLE
… INELIGIBLE
Client’s per diem will be paid by the MSD as per current eligibility less a non exempt income from other.
Per Diem Rate
Sources:
If applicable
$40
Less any non exempt income (monthly amount divided by 30 days) $
Non exempt income from
MSD Per Diem for client
If applicable
Nutritional Subsidy
per month
Completed by
(print name)
Signature
MINISTRY OF OFFICE STAMP
Date
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Early Exit Transition Plan
The following plan will be put in place if I leave early from the Heartwood Centre for Women. I understand that as I continue
treatment the social worker will assist me to develop a more complete transition plan to ensure my continued support and
recovery when returning home.
It is understood that if I leave the program on short notice or if I do not arrive for my scheduled intake, my referral
liaison and my emergency contact will be notified immediately.
Client Name:
Date of Birth (Day / Month / Year):
Community / Health Authority:
Destination upon early exit:
Address:
City:
Shelter
Other MH&A Facility
Independent
Supportive Housing
Residence
Other
(Please Specify):
Community Contact for Early Exit Support
Key Contact for Transition Plan
Name:
Emergency Contact and/or Next of Kin
Telephone:
Email:
Name:
Address:
Telephone:
Email:
Signatures
By signing below, I consent to my referral liaison and emergency contact being contacted. I also understand that If I
leave the program early, my physician will be sent an early discharge summary.
Client:
Date:
Health Authority Referral Agent agrees to the repatriation of the client upon discharge from the Heartwood Centre for
women
Health Authority Referral Agent:
Case Manager:
Date:
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Participation Agreement
I have agreed to apply for treatment at the Heartwood Centre for Women and have reviewed the program services available.
I understand that Heartwood is an abstinence-based program and I agree with the following:
I will participate in the following activities upon arrival to Heartwood and commit to the 90 day treatment program:
• Complete a physical examination with the program physician and nurses
• Meet with the psychiatrist if it is recommended
• Participate in a medication review upon intake.
• Will participate in the required bed bug protocol: shower and wash clothing on admission
• Will treat others with respect, dignity and without discrimination.
• Participate in an assessment and development of a treatment plan and follow this treatment plan
• Participate in group and individual counselling programs
• Will follow the “retreat time” (2 weeks) of the program and not have contact with outside people unless prearranged
with my Treatment Team if there is an urgent need and will not leave the unit without staff permission
• Work with the Heartwood social worker in order to plan a successful return home after treatment
• Follow program guidelines including no violence and no recruitment of others into gangs or prostitution.
• Will restrict or not use any tobacco products during my treatment , consider the goal of tobacco abstinence
• Will abstain from all drugs, alcohol and over-the counter and pharmaceuticals except medication prescribed by the
program physician during my treatment
• Will not use scents during my treatment
• Will not leave the program area unless it is planned with my Treatment Team
• Will restrict visits from family and supports to visiting hours unless otherwise authorized by my Treatment Team
• Will not bring cell phones, cameras, mp3 players, Ipods or personal data devices
• Will keep all information about other program participants confidential
• Will provide urine drug screens and breathalysers when requested by the staff
• Will provide all prescription and non-prescription medications to the nurse
• Will share a room during my stay with up to three other women
• Will not have or store any food items in my room or other non-designated areas of the centre
• Will keep my room clean and clutter free
• Will not have individuals in my room except for staff and my roommates
• Staff may conduct random room searches in my room throughout my stay at the centre
• Will take all my belonging upon discharge. Belongings left after discharge from the centre will be donated to charity
Signatures
Client:
Date:
Referral Agent:
Date:
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