Fillable Frm-18020 Residential Adult Addiction Treatment Program Application

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Frm-18020 Residential Adult Addiction Treatment Program Application

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18020(2016-03)
Residential Adult Addiction Treatment
Program Application
Page 1 of 9
Office Use Only
Client ASIST #
A room and board fee of $40.00 per day for Alberta residents, $125.00 per day for out-of-province residents and
$200.00 per day for clients attending the Business and Industry Clinic will apply.
Please complete pages one to five of this form and have the referring person
(if applicable) complete page six. The
medical assessment on pages seven to nine must be completed by a medical doctor or nurse practitioner.
Return all pages by fax or by mail to the appropriate centre below. Unanswered questions, incomplete or illegible
answers may delay your admission.
Please check the centre you are applying for. You may only select one.
o Business and Industry Clinic o Northern Addictions Centre
11333 - 106 Street 11333 - 106 Street
Grande Prairie, AB T8V 6T7 Grande Prairie, AB T8V 6T7
Phone: 780.538.6316 Fax: 780.538.6313 Phone: 780.538.6350 Fax: 780.538.6313
o Lander Treatment Centre o Henwood Treatment Centre
P.O. Box 1330 18750 18 Street NW
221 - 42 Avenue West Edmonton, AB T5Y 6C1
Claresholm, AB T0L 0T0 Admissions: 780.422.4466
Admissions: 403.625.5600 Switchboard: 780.422.9069 Fax: 780.422.5408
Switchboard: 403.625.1395 Fax: 403.625.1300
o Fort McMurray Recovery Centre o Medicine Hat Recovery Centre
451 Sakitawaw Trail 370 Kipling Street SE
Fort McMurray, AB T9H 4P3 Medicine Hat AB, T1A 1Y6
Phone: 780.793.8300 Fax: 780-793-8301 Phone: 403.529.9021 Fax: 403.529.9065
Legal name (last, first, middle)
What name do you like to be called? Other name (e.g. maiden name or an alias)
Marital status (Choose one only)
o Single/Never married o Married/Common-Law/Partnered o Widowed
o Separated o Divorced
Mailing Address
Three months ago, were you a resident of a province or territory other than Alberta?
o No
o Yes, what date did you take up residency in Alberta?
(yyyy-Mon-dd)
(proof of Residency may be required)
What is your occupation? Who is your employer?
If your application was prompted, please check all that apply
o Addiction Services Office o Physician
o Child Welfare Worker o Psychiatrist/Psychologist/Mental Health Worker
o Addiction Funded Agency o Employer/Employee Assistance Program
o Social Services/Income Support Worker o Court/Parole Office/Probation Officer/Lawyer
o Other
(specify)
Home Phone Alternate or Cell Phone Fax Number
City Province Postal Code
Date of Birth (yyyy-Mon-dd) Personal Health Number (PHN) Age
o Male
o Female
Regular Substance
What do you use most often?
Pattern of use (e.g. daily, binge)
How long have you used this substance?
How long has this been a problem for you?
Date you last used this substance? (yyyy-Mon-dd)
Other Substance Used
What other drug do you use?
Pattern of use (e.g. daily, binge)
How long have you used this substance?
How long has this been a problem for you?
Date you last used this substance? (yyyy-Mon-dd)
Other
What other drug have you used?
Pattern of use (e.g. daily, binge)
How long have you used this substance?
How long has this been a problem for you?
Date you last used this substance? (yyyy-Mon-dd)
Gambling
Types of gambling done? (e.g. VLT, bingo, horse gambling)
Pattern of gambling (e.g. daily, weekends, paydays)
Amount of money gambled per occasion
How long have you gambled?
How long has this been a problem for you?
Date you last gambled? (yyyy-Mon-dd)
Please describe in detail your alcohol, other drug use and/or gambling.
Page 2 of 9
Residential Adult Addiction Treatment
Program Application
18020(2016-03)
Describe in detail how your drinking, drug taking and/or gambling affected you and your life? (e.g. effects on family
relationships, employment, health, social life, etc.)
Treatment history for alcohol, drug or gambling problems
Have you previously attended Alberta Health Services residential addictions treatment?
o No
o Yes, check all that you’ve attended below
▼
o Business and Industry Clinic o Lander Treatment Centre o Northern Addictions Centre
o Fort McMurray Recovery Centre o Henwood Treatment Centre o Medicine Hat Recovery Centre
Other treatment agencies attended
Reason(s) for previous treatment
Approximate date(s)
How long did you remain alcohol, drug or gambling free after treatment?
What are your reasons for wanting to attend residential treatment at this time?
Do you have any special needs or problems that we need to be aware of? (e.g.reading and writing English, wheelchair
accessibility, hearing difficulties, problems with stairs and long corridors)
o No
o Yes, give details
Do you have any allergies? (medications, foods, environmental)
o No
o Yes, list them
List all medications that you are taking, including all over-the-counter drugs. (e.g. Gravol, Tylenol, NyQuil, allergy
medications, vitamins, herbal remedies, etc.)
Are you seeing a doctor regularly for any reason, including just refilling medication?
o No
o Yes, explain
Page 3 of 9
Residential Adult Addiction Treatment
Program Application
18020(2016-03)
Describe current medical problems (e.g. chronic health issues, recent surgery, injuries, pain, etc.)
Have you ever experienced mental health concerns? (e.g. panic attacks, hallucinations/delusions, uncontrollable rage, mood
swings, mental illness, etc.)
o No
o Yes, what are the problems?
Describe in detail how the above problems affected you or others both in the past and currently
If currently under the care of a doctor/psychiatrist/psychologist, complete boxes below ▼
Have you had any thoughts of suicide or self-harm?
o No
o Yes, describe in detail
If you have a history of criminal convictions, list the type and approximate dates of conviction(s)
Describe any outstanding or pending legal charges
Name Phone Number
Page 4 of 9
Residential Adult Addiction Treatment
Program Application
18020(2016-03)
Page 5 of 9
If applicable, list upcoming court dates
Are you currently incarcerated/in jail?
o No
o Yes, which institution
Are you on Probation, Temporary Absence or Parole?
o No
o Yes, complete below
▼
Is there anything else you feel we should know?
Type of Offence Name of Parole/Probation Officer
Parole/Probation Officer’s Phone Parole/Probation Officer’s Agency/Office
Residential Adult Addiction Treatment
Program Application
18020(2016-03)
Check method of payment
o Cash o Certified Cheque o Money Order o Visa o Mastercard
o Social Services,
If checked, provide 3rd party contact information
o Health Canada/Indian Affairs
If checked, provide 3rd party contact information
o Other
(explain)
Carefully Read the Following
< I understand in order to be admitted to residential treatment, I must remain alcohol and drug free for at
least five days prior to my admission date, and be well enough to participate in the program. If I arrive
under the influence of alcohol or other drugs, or in withdrawal requiring clinical intervention, I will be
referred to an appropriate detoxification setting before treatment.
< I understand Alberta Health Services (AHS) is not responsible for my transportation or any other personal
costs I may incur
(e.g. approved medications) while I am in treatment. I will bring and give to staff all
medications I am taking.
< I understand I cannot schedule any appointments (legal, dental, medical or personal) for the period while in
treatment. I must focus on my treatment program.
< I understand and agree to accept and attend all components of the treatment program as prescribed by
AHS, including all workshops, lectures, leisure and group counseling sessions.
Signature Date (yyyy-Mon-dd)
The personal information collected by this application is collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy
Act and section 20 of the Health Information Act and will be used and disclosed by AHS for verifying the statements in this application and for determining
admission to Residential Adult Addictions Treatment Program. If you have questions about this program please call one of the treatment centres. If you have
any questions about AHS' privacy policies and practices, please contact Information and Privacy at 1-877-476-9874. You may also write to Information and
Privacy at 10301 Southport Lane SW, Calgary, Alberta T2W 1S7 or email us at privacy@albertahealthservices.ca
Type of Referral (check the box which most applies)
o AHS Addiction Services o Health/Medical – Doctor o Business/Workplace, specifically:
o Other Addictions Agency o Health/Medical - Other o EAP
o Relative/Friend o Mental Health o Human Resources
o Pastoral o Justice Legal o Occupational Health
o WCB/Disability Management o Private Employer
o Other
(specify)
What is your assessment of the applicant’s readiness and motivation for residential treatment?
Other than alcohol, drug or gambling, what issues does the applicant need to address while in the program?
Referral’s Signature Date (yyyy-Mon-dd)
Page 6 of 9
This section is to be completed by the referring person only
Referring Person’s Name
Agency Professional or Personal relationship to applicant
Business Address
Postal Code Phone Number Fax Number
City Province
Please note you can not self refer to the Northern Addictions Centre. You must have a referring person to apply.
All referrals must be on a professional basis; referrals from friends or family are not accepted.
o Self-referral, skip this section
Residential Adult Addiction Treatment
Program Application
18020(2016-03)
Residential Adult Addiction Treatment
Program Application
Patient Name (last, first, initial) Date of Birth (yyyy-Mon-dd)
Personal Health Care Number
Allergies (e.g.drug, food, medical tape, other)
This medical assessment is required as part of the application and must be completed in full by a medical
doctor or nurse practitioner. The cost of fully completing this medical is covered by Alberta Health Care.
Review of Systems (please send relevant reports, e.g. CBC, hepatic profile, electrolytes, urinalysis, fasting blood glucose)
EENT
Respiratory (e.g. asthma, COPD) Cardiovascular (e.g. CVA, MI, HTN, arrythmia, pacemaker)
Gastrointestinal (e.g. GERD, history GI bleed, hepatitis,
pancreatitis)
Genitourinary (e.g. incontinence, BPH, STD)
Musculoskeletal (e.g. chronic pain, RA,OA, gout) Integumentary (e.g. psoraiasis, eczema)
Neurological
Does the patient have a history of seizures? o No
o Yes
Hematological/Immune (e.g. HIV+, HCV+)
Evidence of withdrawal or intoxication? (e.g. ETHO, OPIOID) Other (specify)
Pregnancy
Is the patient pregnant?
o No, complete top boxes only
►
o Yes, complete all boxes ►
Does the patient have current pregnancy complications or had a history of pregnancy complications?
o No
o Yes, specify
Physician managing the pregnancy and delivery Phone Fax
Address of planned location of delivery
Physical Examination
Skin Diaphoresis Tremor
Needs assistance ambulating or providing self care? o No o Yes
Height Weight Temperature Pupils Heart rate Blood pressure Respiration rate
Is the patient diabetic? o No
o Yes, complete this information
►
(need recent HbAIc result)
Year diagnosed
Is the patient stable? o No
o Yes
Page 7 of 9
Does the patient have MRSA and wound?
o No o Yes,
(specify latest swab results)
Is there cognitive impairment? o No
o Yes
LMP Para Gravida
EDC Urine hCG Prenatal blood work Prenatal ultrasound Blood type
18020(2016-03)
TB Screening - Symptoms and History
Check the appropriate boxes No Yes
Presence of cough lasting more than 2 weeks
Weight loss, if yes specify lbs. in length of time
Night Sweats
Fever
Fatigue
Haemoptysis (blood in sputum)
Previous active TB and treatment
Previous significant Mantoux or chest x-ray results
Extensive travel (or birth) in a country with high incidence of TB
Other risk factors (i.e. aboriginal, elderly, homeless, health care worker)
Poor general health status and risk factors for progress of disease
Further TB screening/assessment required -if yes please send results to appropriate centre
Is there evidence of the following? (please include your judgement related to current severity of mental health concerns)
a
No Yes Comments
Mental, developmental and/or learning disorders (e.g. depression,
anxiety disorder, bipolar disorder, ADHD, phobias, psychosis, schizophrenia)
Underlying pervasive or personality conditions (e.g. personality
disorders, mental retardation)
Acute medical conditions and physical disorders aggravating
mental health (e.g. brain injury, cognitive impairment, chronic pain, insomnia)
Contributing psychosocial and environmental factors.
Global Assessment of Functioning
Is there a history of self-harm, suicidal thoughts or suicide
attempts? (If yes, pertinent psychiatric reports/assessments are required)
Psychiatric Review/History (send psychiatric evaluations and/or discharge summaries if available)
Addictions-note date of last use, pattern of abuse and severity of addiction (e.g. alcohol, cocaine, opioids, cannabis,
gambling, tobacco, etc.)
Primary Secondary Tertiary
Medical Approval
In your opinion is this patient medically stable and appropriate for admission to Residential Addiction Treatment?
o No o Yes
Physician or Nurse Practitioner’s Name (print) Signature Date (yyyy-Mon-dd)
Psychological Approval
In your opinion is this patient psychologically stable and appropriate for admission to Residential Addiction
Treatment? o No o Yes
Physician or Nurse Practitioner’s Name (print) Signature Date (yyyy-Mon-dd)
Page 8 of 9
Patient Name (last, first, initial) Date of Birth (yyyy-Mon-dd)
PHN
Residential Adult Addiction Treatment
Program Application
18020(2016-03)
Medications (if more room is needed, attach list. Send relevant laboratory results e.g. current INR, Lithium or Phenytoin levels)
Medication Dose Route Frequency Reason
given
Start date End date Prescribed by Phone
number
Please remind patient that in order to be admitted to Residential Adult Addictions Treatment Program, they
need to:
< Be well enough to participate in the program and remain alcohol and drug free for at least five days
prior to admission.
< Ensure any new medications not listed above have been pre-approved by Treatment Program nurse.
< Bring enough of their medications (in the original packaging from the doctor or pharmacist) for their time in treatment.
< If the patient’s medical or psychological condition changes before their scheduled admission date they must
contact the Treatment Program.
Page 9 of 9
Physician/Nurse Practitioner’s Name (print)
Mailing address
Primary Physician Name (if different than above) Phone Fax
Other (e.g. psychiatrist or other specialist relevant to this admission) Phone Fax
Primary Care Network affiliation? o No
o Yes, complete this information
▼
Name Address
City Postal Code Phone Fax
Signature Date (yyyy-Mon-dd)
Physician Stamp
Patient Name (last, first, initial) Date of Birth (yyyy-Mon-dd)
PHN
Residential Adult Addiction Treatment
Program Application
18020(2016-03)
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Completed 18 July 2020

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