Fillable Form 1: INITIAL CONTACT PACKAGE (ICP) Referral Source

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Form 1: INITIAL CONTACT PACKAGE (ICP) Referral Source

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Country of origin: CANADA
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1
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INITIAL CONTACT PACKAGE (ICP)
Referral Source Self External Agency
Referring Agency
: _____________________________
Name of Worker: ___________________________ Completed by: _______________________
Contact information of worker: ________________________________________________________
DEMOGRAPHIC INFORMATION
Client Name: __________________________ Gender: _______________________________
Date of Birth M/D/Y: ____________________ Full Address: __________________________
Phone Number: __________________________ ______________________________________
Cell/Alternate: __________________________ ______________________________________
Mailing Address if different from above: ______________________________________________
Email: _________________________________ ____________________________________
Can we leave: Voice Message Text Message
Email
Other __________________
If under the age of 18 name of parent or guardian: ________________________________________
Phone number: ____________________________________________________________________
Emergency Contact information if no emergency contact please tell us why:
_________________________________________________________________________________
Self-Identification: First Nation
Metis
Inuit Non-Status Other ___________
Status card
# & Band
if applicable: ____________________________________________________
Health card
& code with
Expiry Date: ________________________________________
Are you a descendant or Residential School survivor: Yes No Unknown
Name of Residential School if known: _________________________
Date: ____________________ In person Telephone Other: ____________
Information provided by (check all that apply): Client Guardian Worker
Revised September 17, 2020
2
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Do you have a family member or friend that is currently employed with Enaahtig Healing Lodge and
Learning Centre or any of its divisions? Or have you ever been employed with Enaahtig
Healing Lodge or any of its divisions.
Yes
N/A
I am an employee of Enaahtig Healing Lodge
Yes
N/A
I have a family member or friend who is employed with Enaahtig Healing Lodge
FAMILY COMPOSITION
Relationship status: Single Married Common Law Divorced Separated
N/A
Children: Yes No
Does the
youth
have any
siblings: Yes No
Are the children in the care of the parents: Yes
No If no, please provides information below:
____________________________________________________________________________________
____________________________________________________________________________________
Please
provide date/s
of apprehension applicable: ____________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Name Gender Relationship
D/O/B
/ And Age
Please identify any family members
living inside or outside of the home,
as well as anyone else living in the
home
Revised September 17, 2020
In a relationship
Widowed
3
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EDUCATION AND WORK HISTORY
Education: Elementary ______________________________________________________
Secondary _______________________________________________________
Post-Secondary ___________________________________________________
Income: Employed Ontario Works ODSP Unemployed Other
Employer: ___________________________________________________________________
When completing identifying
issues please ensure to provide as much information as possible.
IDENTIFYING NEEDS
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
ARE THERE
ANY MENTAL
HEALTH NEEDS
TO BE
CONSIDERED?!
!
ARE THERE
EMOTIONAL
NEEDS TO BE
CONSIDERED?
!
Spiritual
Physical!
Mental
Emotional
ARE THERE
SPIRITUAL
NEEDS TO BE
CONSIDERED?
ARE THERE
PHYSICAL
NEEDS TO BE
CONSIDERED?
Revised September 17, 2020
4
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MEDICAL INFORMATION
Mental Health Diagnoses/Name of Assessor:
Date of Diagnosis: _____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Have you had any assessments? If yes, please provide copies:
___________________________________
____________________________________________________________________________________
Medications
Dosage
What is it used for?
& Last Used
How is it administered
Frequency of useSubstance Alcohol, Drug, Cigarettes Date last used
Allergies: ____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________
Revised September 17, 2020
5
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LEGAL COMPLICATIONS
Do you currently have any court matters before the court or restrictions we need to be aware (probation,
peace bonds, etc)? Please include any relevant custody orders or terms of care agreements if applicable:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________
Please list :
___________________________
Enaahtig Locations:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Revised September 17, 2020
Fax: (705) 330-4067
(705) 330-4059
L3V 5E3
Orillia, ON
334 West Street
Enaahtig Outreach
Fax: (705) 857-3266
(705) 698-1577
P0M 1A0
Alban, ON
490 A&B Hwy 607A
Enaahtig North
Fax: (705) 526-7557
(705) 526-2929
L4R 3M9
Midland, ON
382 King St
Enaahtig Justice
4184 Vasey Road
Enaahtig Central
Fax: (705) 534-4991
(705) 534-3724
L0K 2A0
Victoria Harbour, ON
Which Program is the ICP for:
Youth Res.
Therapy
Family Res./
Trauma Prog
Outreach
Justice
What services are you specifically looking for from Enaahtig Healing Lodge & Learning Centre:
Please list all services and what you hope to achieve from referral:
_____________________________________________________________________________________________________
__
_____________________________________________________________________________________________________
__
_____________________________________________________________________________________________________
__
_____________________________________________________________________________________________________
______________________________________________________________________________________________________
_
Have other referrals been made:
6
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CONSENT FOR REFERRAL/INTAKE
Statement of Understanding and Consent
I, ______________________________, understand that by signing this form, I have acknowledged
consent to receive services and attend programming from Enaahtig Healing Lodge and Learning Centre
for myself or the child/youth listed below. I have read and understand the information provided and that
have given my permission to have an intake interview conducted in order to offer services. Furthermore,
I understand that this in no way obligates me to Enaahtig Healing Lodge and Learning Centre.
Furthermore, I consent to my information being shared with the different services within Enaahtig
Healing Lodge and Learning Centre including Enaahtig Outreach Mental Health Team, Enaahtig Justice
Team, Enaahtig Therapist Team and Enaahtig Residential Programming Team when needed for my plan
of care.
(If consenting for a minor child, please indicate child’s name on the right)
__________________________________________________________________
Signature Month / Day / Year Child’s name
__________________________ _____________________
Month / Day / Year
Witness
If you are signing for a minor child/ward, what is your relationship with the child/ward?
__________________________________________________________________________
Revised September 17, 2020
7
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LIMITS OF CONFIDENTIALITY
Enaahtig Healing Lodge and Learning Centre staff will explain the following information to you. Your
signature indicates that you understand and accept the limits of confidentiality. Please feel free to ask any
questions you may have pertaining to confidentiality and we will be happy to explain this form and the limits to
confidentiality.
Sharing Information
I understand that Enaahtig Healing Lodge and Learning Centre will be asking me for personal information and
personal health information to ensure alignment of services. The purpose of the assessment is to develop a plan
of care that will support my goals, wellness and recovery. This information will be used to develop a plan of
care that may include internal or external referrals and collection of information. This information will be kept
in both a hard file as well as an electronic file. Enaahtig Healing Lodge uses a web-based client file system
(EMHware) for the creation and storage of client clinical data. This system requires a username and unique
individualized password that are provided only to the Enaahtig Healing Lodge staff member.
No individual outside of Enaahtig Healing Lodge and Learning Centre will have access to these files without
your written consent. Furthermore, consent can be withdrawn at any time with a written request. Enaahtig
clients can request to access their own personal health records by submitting a written request to the Intake
Coordinator or Case Manager.
I also understand that there are circumstances where confidential information is legally required to be
shared without my written consent. They are as follows:
•
When a client is not capable of giving consent
•
If
we
believe that you are in immediate threat to self or others, we are obligated to report this to the
proper authorities for the protection of all involved
•
We are required by law to report sexual abuse by another regulated health professional
•
Suspected or known abuse of a child 16 years of age or under “current”
•
In addition, files can be subpoenaed by the court
________________________________ _____________________________________________
Client Name (Please print)
Signature
_________________________________ _____________________________________________
Witness (Please print)
Signature
Date M/D/Y
Date M/D/Y
Revised September 17, 2020
8
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THE PERSONAL INFORMATION ACT
The Personal Health Information Protection Act, 2004 is a provincial law that governs the collection, use and
disclosure of personal health information within the health care system. The object is to keep personal health
information confidential and secure, while allowing for the effective delivery of health care services. Under this
legislation, health care providers and others who deliver health care services are collectively known as health
information “custodians.”
What is personal health information?
Personal health information includes any identifying information about an individual’s health or health care
history, such as your family medical history, details of a recent visit to your doctor, or your Ontario health card
number
Do health information custodians need my permission to access my personal health information?
Custodians are permitted to collect, use and disclose your personal health information, on the basis of implied
consent, for providing your health care.
What are heath information custodians required to do? Under PHIPA, health information custodians are
required to: 1) collect only the information they need to do their job 2) take steps to safeguard your personal
health information 3) take reasonable steps to ensure your health records are accurate and complete for the work
they do 4) provide a written description of the practices they use to protect your information, and the name of the
person to contact if you have any questions or concerns about your personal health records. What are your
rights under PHIPA?
PHIPA gives you the right to: 1) give permission (consent) to how your personal health information is collected,
used and shared 2) request access to your health records 3) make corrections to your records
For more information of your personal health information rights under PHIPA: Service Ontario Information
Line: 1-866-532-3162 (Toll-free)
. PERSONAL INFORMATION AND CONSENT NOTICE
This Notice and Consent is intended to inform you how we will collect, use, disclose, and destroy your personal
information.
Your personal information may be collected formally, in writing, and informally. Only necessary information will
be collected about you. We will collect, use, and disclose information about you for the following purposes: To
develop plans of care and practice case management of your file; To enable accurate referrals are made; For
anonymous statistical analysis of programs and services. The storage, retention, and destruction of your personal
information complies with this agency’s policy, applicable legislation and privacy protection protocols. We are
willing to provide a copy of our policy to you at your request.
Your consent may be withdrawn at any time by written notice to this agency. You may access you own personal
information or request corrections through a written request to this agency. This consent form will serve for all
agency programs you access, with one program designated as your primary provider and your original consent
kept in that program file.
Revised September 17, 2020
9
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*Please note: A substitute decision-maker is a person authorized under PHIPA to consent, on behalf of
an individual, to disclose personal health information about the individual.
Consent to Disclose Personal Health Information
Pursuant to the Personal Health Information Protection Act, 2004
(PHIPA)
I
authorize,
,
(Print Name of Health InformationCustodian)
Date
of
Birth:
Health
Card:
Ver:
to disclose
my personal health information consisting
of:
(Describe the personal health information to be disclosed)
or
the personal health information of:
(Name of Person for whom you are the substitute decision-maker*)
consisting of:
(Describe the personal health information to be disclosed)
Enaahtig Healing Lodge and Learning Centre
to
(Print name and address of
person requiring the information)
I understand the purpose for disclosing this personal health information to the person noted
above. I understand that I can refuse to sign this consent form.
My
Name:
Address:
Home
Tel.:
Work
Tel.:
Signature:
Date:
Witness
Name:
Address:
Home
Tel.:
Work
Tel.:
Signature:
Date:
Revised September 17, 2020
(Print your name)
(Month / Day / Year)
10
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INDIVIDUAL CONSENT
Always complete this part if the Individual is capable of consent.
Individual refers to “client.”
I, _________________________________ (“The Individual”) have read and understood the
preceding notice and had it explained to me. I am aware how this agency will use my personal
information. I am also aware of the steps taken by this agency to protect my information, when
it is collected, used or disclosed as well as how it will be stored and destroyed. I consent to the
provisions of the preceding Notice.
Signature: _______________________________
Date:
________________________
Witness: ________________________________
Date:
________________________
Complete this part if the person is under the age of 16 years or if a substitute, decision
maker has been named.)
I am the: ___________________________ (parent, guardian, surety, etc.) of:
____________________________. I have read and understood the preceding notice and had it
explained to me. I consent on behalf of the individual to the provisions of the preceding notice.
Name: __________________________________
Signature: ________________________________
Date:
___________________________
Name: ___________________________________
Witness:__________________________________
Date:
___________________________
Revised September 17, 2020
11
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CONSENT TO EXCHANGE OR RELEASE OF CONFIDENTIAL INFORMATION
I, ________________________ (Name) consent on behalf of myself
Or ________________________ (Name of child if consenting for a minor) to the
exchange and/or release of personal information collected about the above named persons. I
authorize employees of Enaahtig Healing Lodge and it divisions to share personal information
collected about me and or the name of child above to the selected agencies below.
I have
initialled beside those service providers/agencies that I agree may share my personal
information. For the purpose of assessment for programs and services, also for the purpose of
ongoing treatment of my family and myself, I understand that I may withdrawal my consent at
any time by providing notice in a written withdrawal request.
___ Barrie Area Native Advisory___ Barrie Native Friendship Centre
___ Biminaawzogin Regional Aboriginal Women’s___ Beausoleil First Nation Health Centre
___ Catulpa Community Living Supports Services___ Canadian Mental Health Association
___ Chippewa’s of Rama Community Mental Health and Family Services
___ CSC Chigamik ___Crown Attorney
___Community Living ___ David Busby Street Centre
___Defence/Duty Counsel___ Dnaadgawenmag Binnoojiiyag (DBCFS)
___ Elizabeth Fry Society ___Georgian Bay Native Friendship Centre
___Georgian Bay Native Women’s Association ___ Metis Nation of Ontario
___ Ontario Works___ Orillia Native Women’s Group
___ Ontario Disability Support Program (ODSP) ___Salvation Army
___Simcoe/Muskoka Family Connexions
___ Waypoint Centre for Mental Health Care
___ Other __________________________
___Other ___________________________
Date:
_________________________________
Date: __________________________________
___ S.U.N Housing
___Probation/Parole
___ Other __________________________
___Other __________________________
Name:
_________________________________
Signature: ____________________________
Witness: _______________________________
Revised September 17, 2020
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Form 1: INITIAL CONTACT PACKAGE (ICP) Referral Source

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Completed 22 October 2020

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