Admission Forms - Kelowna Hills Recovery Centre

Residential Recovery Program Kelowna, BC Phone: (250) 859-­‐4472 http://kelownahillsrecovery.org Residential Recovery Program Admission Package Admission Criteria Clients to be 19 years of age or over, a referral is not requited. Clients to confirm a realistic starting date with staff. Clients to be free from mood-­‐altering substances such as benzodiazepines, codeine, and barbiturates. Can be on medically supervised tapers. Clients stabilized on anti-­‐depressants and/or methadone are accepted. Clients to be medically able to participate in the program. Clients to be emotionally able to participate in group therapy. Clients must be able to defer any pending court dates until after treatment. Clients must be able to understand and speak English. Client must be committed to making changes. I.
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Application Forms A.
Admission Form to be completed by Client. (Parts #1-­‐ #8) B.
Medical Assessment Form to be completed by Physician. (Parts #9-­‐ #12) The Client’s physician should complete this form. If it is not completed by the Client’s physician, it will be completed or by the Centre’s physician on arrival. Kelowna Hills Recovery Centre 1 of 8 Residential Recovery Program A.
Admission Form to be completed by Client
Part #1: CLIENT INFORMATION Name: ______________________________________________________________________ Occupation: ____________________________________ Address: _______________________________________________________________City: ________________________ Prov./State ___________ Phone (Home) ___________________ (Cell) ______________________ e-­‐mail address: ___________________________________________ Date of Birth ( yyyy/mm/dd) __________________ Marital Status: __________________ Health Card # ___________________________ Number of Children, & Ages, Living with Client: __________________________________________________________________________ Sport, Interest or Hobby: #1________________________________ #2 ____________________________ #3____________________________ Emergency Contact: _______________________________ Phone: (Home) ________________________ (Cell) _______________________ Part #2: SOURCE OF INFORMATION (if being completed by someone other than client) Name: __________________________________________________ Relationship to Client: _______________________________ Phone: (Home) __________________________ (Cell)_______________________ Part #3: FUNDING Provider (If different from the client) Name: ____________________________________________________________________________________________________________ Address: _________________________________________________________________________________________________________ City: __________________________________ Prov./State _______________________ Postal/Zip code: _________________ Phone: (Home) ______________________ (Cell) ______________________Relationship to Client: ____________________ Part # 4: PAYMENT (prior to, or on arrival) How will you be paying? Credit Card Bank Check Money Order
Please Print, scan and Submit by Email to mailto:pattermac2@gmail.com Kelowna Hills Recovery Centre 2 of 8 Bank Transfer Residential Recovery Program Part #5: ADDICTION SUMMARY (Please list all substances used over the past 6 months and circle your Drug of Choice) Substances used Alcohol Marijuana Cocaine/Crack Heroin Ecstasy (MDMA) GHB Crystal Meth (amphetamines) Psilocybin (mushrooms) Benzodiazepines LSD (acid) Prescription Medication Misuse? (Please list) Other Substance Misuse? (Please list and explain) Methadone Maintenance Program Cigarette Smoker? Other Addictive Behaviors Frequency of use. Average consumption. Date last used. How often Last time How managing? (Please list and explain using boxes to the right, e.g. gambling, sex, shopping, internet) Eating Disorders (last 6 months) Binge Eating Eating Restrictions Vomiting/Purging Laxative/Enema Abuse Diuretic Abuse Excessive Exercising Part # 6: LEGAL HISTORY Please select all that apply History of Violence? Possession, Trafficking of Narcotics?
Current legal involvement? Parole obligations? If yes to any of these please explain. Please Print, scan and Submit by Email to mailto:pattermac2@gmail.com Part # 7: HEALTH ASSESSMENT
Kelowna Hills Recovery Centre 3 of 8 Residential Recovery Program Previous Treatment/Counselling: (please list) Treatment Type Date completed Number of sessions Physical conditions (e.g. migraines, dental, chronic back pain, withdrawal symptoms) that may impact client's participation in treatment or require medical follow-­‐up during treatment. If any conditions are present, please explain Methadone Maintenance Program Is the client on methadone maintenance? Yes No If yes, for how long? _______________ Prescribing Doctor _____________________________ Phone: _______________________ Fax: ________________________ Current Dosage: _____________ Any impact on client's alertness after dosing? Yes No Part # 8: Intensive Residential Treatment Readiness Does client have a history of physical abuse?: Yes No Sexual abuse: Yes No Has client ever had a medical diagnosis of psychiatric illness? Yes No If yes to any of these, please provide detail, and how managing the diagnosis. Bi-­‐Polar Yes No Depression Yes No Anxiety Yes No Other Psychiatric illness Yes No Please Print, scan and Submit by Email to mailto:pattermac2@gmail.com Kelowna Hills Recovery Centre 4 of 8 Residential Recovery Program Current Prescribed Medications: (please list) Medication Name Dosage Reason for use Over the counter medications: (please list) Medication Name Dosage Reason for use Are any Health Risk Behaviors currently present? (Within the last 6 months): Health Risk Behaviors How often Last time How managing? Seizures Suicide attempts Self inflicted violence Hospitalization for psychiatric illness Others behaviors (Please list and explain using boxes to the right) General Considerations: What recent involvement has the client had with self-­‐support groups, i.e. NA, AA, etc.? What are the client's particular strengths and abilities? What are the overall treatment goals for the client? Please add any additional information that might assist the counselling team in their work with the client. Please Print, scan and Submit by Email to mailto:pattermac2@gmail.com Kelowna Hills Recovery Centre 5 of 8 Residential Recovery Program Kelowna, BC Phone: (250) 859-­‐4472 http:// kelownahillsrecovery.org Dear Doctor:
Your patient has applied for admission to the Kelowna Hills Recovery Centre. The
Centre provides an intensive group treatment program for addictions. The Centre is a
non-medical facility; so all clients must be medically stabilized and detoxified prior to
admission.
During treatment emergency care is available on a 24-hour basis through hospital
emergency departments off site. It is expected that clients admitted to our program
be able to participate mentally, emotionally, and physically in the intensive program
without the need for ongoing medical care. We would appreciate it if you could fill in
the accompanying medical form. The patient will be responsible for any fee you
charge for this service.
Clients being treated at Kelowna Hills Recovery Centre must have completed
withdrawal from alcohol and drugs and have a one-week period of abstinence prior
to entry into the program.
Potentially addictive medications such as opiates,
benzodiazepines and barbiturates are not allowed unless on a taper. Please ensure
that any medical condition such as Chronic Pain Syndrome and migraines are well
controlled without the need of medications. We do admit clients stabilized on
methadone therapy.
Other inappropriate referrals to Kelowna Hills Recovery Centre include persons with
the following disorders: - Paranoid and other fixed delusions- Auditory, visual,
olfactory, or kinesthetic hallucinations- Suicidal ideation- Other thought disturbances
which seem out of the person's control and not accessible to efforts for change.
Previous experience indicates these conditions impair the ability of the client to form
functional relationships with other clients and staff, and usually lead to failure to
complete the program.
If in doubt, please feel free to contact Kelowna Hills
Recovery Centre Treatment Centre for further discussion about your patient's needs.
If you become aware of any reason why your patient would not be appropriate for
the program, please inform us as soon as possible.
Please Print, scan and Submit by Email to mailto:pattermac2@gmail.com Kelowna Hills Recovery Centre 6 of 8 Residential Recovery Program B.
Medical Assessment Form to be completed by
Physician
Part #9: CLIENT INFORMATION Date:_______________________________ Patient Name _____________________________________________________________DOB _______________________________ Address _________________________________________________________________________________________________________ Occupation _______________________________________________________________________ Medical History ________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Psych History ___________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Surgical History _________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Medications ____________________________________________________________________________________________________ Allergies __________________________________________________________________________ Anakit ____________________ Part #10: LAB Liver Function Test: HIV: Hepatitis B: Hepatitis C: Yes No Yes No Yes No Yes No Please Print, scan and Submit by Email mailto:pattermac2@gmail.com Kelowna Hills Recovery Centre 7 of 8 Residential Recovery Program Part #10: DRUG HISTORY Name of drug Alcohol Marijuana Cocaine/Crack Heroin Ecstasy (MDMA) GHB Crystal Meth (amphetamines) Psilocybin (mushrooms) Benzodiazepines LSD (acid) Prescription Medication Misuse? (Please list) Other Substance Misuse? (Please list and explain) Dosage Date of last use Part #11: REVIEW OF SYSTEMS ENT __________________________________________ CVS __________________________________________ NEURO ______________________________________ SKIN _________________________________________ GYNE G__________ P___________ A___________ CHEST_______________________________________ ABD__________________________________________ M/SK ________________________________________ ENDO ________________________________________ CYCL _________________________________________ Part #12: PHYSICAL EXAM HEIGHT _________ WEIGHT __________ BP __________________ PULSE ________________ ENT ___________________________________ CHEST ________________________________________ CVS ____________________________________ ABD __________________________________________ NEURO ________________________________ M/SK _________________________________________ SKIN ___________________________________ ENDO _________________________________________ SUMMARY________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Client is medically and physically able to participate in an intensive group-­‐counselling program. Physician ______________________________________________________ Please Print, scan and Submit by Email to mailto:pattermac2@gmail.com Kelowna Hills Recovery Centre 8 of 8