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RESIDENTIAL TREATMENT PROGRAM Part I Application for Admission

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Box 291, 21060 Tranquility Way, Blackfoot, AB T0B 0L0 | T: 1.877.875.8890 | F: 780.875.2161 | info@thorperecoverycentre.org |
thorperecoverycentre
.org
Charitable Registry #108189093 RR0001 | MHSPA 10000021
Together we improve lives
through overcoming addiction
& mental health concerns.
RESIDENTIAL TREATMENT PROGRAM
Part I – Application for Admission
Applicant Name: _______________________________________ Application Date: _______________
Office Use Only
Admission Date: _______________ Discharge Date: ________________ File #: _________________
Confirmation Date: _____________
In order to assist with your admission in a timely matter please complete our pre-admission package. This
information will help us in determining whether Thorpe Recovery Centre can meet your needs for addiction
recovery.
Failure to comply with the following rules and regulations or accurate completion of this package may
result in delayed or cancelled admission.
Enclosed You Will Find:
Conditions of Admission Pg. 2
An overview of what you can expect at Thorpe Recovery Centre so you may make an informed decision whether
we are the right fit for you. Further information can be found within our Client and Family Handbook on our
website.
Contract of Services Pg. 5
An agreement of what to expect and what we expect from you.
Applicant Information Pg. 10
To be completed by the applicant and/or the referral source.
Pre-Admission Collection & Release of Information Pg. 17
Authorizing those who assist in your mental and physical well-being to communicate with Thorpe Recovery
Centre regarding your treatment.
Packing Checklist Pg. 18
A listing of what you need to bring for your stay at Thorpe Recovery Centre. There is also a list of items that will
not be permitted into the building.
Information for the Client’s Support Network Pg.19
Information for family members, friends, and/or employers to understand your experience at the Centre. We also
provide some insight on how to support you in recovery.
To be completed by a physician (available on website)
Pre-Admission Medical Assessment
so that The Thorpe Recovery Centre medical team may access any medical and psychiatric needs necessary for
providing effective care.
Restricted Medications
For your health and safety, we only permit certain medications in the facility. Discuss this list with your physician
prior to your admission.
Submit this completed application to admissions@thorperecoverycentre.org
PART I – RAT Application
V6. Updated October 1, 2020
2/21
Conditions of Admission
The following information is set out to ensure the efficient processing of applications of those who wish to seek
treatment at the Thorpe Recovery Centre. Failure to adhere to agency rules and policies will result in termination
of treatment.
A. CONFIRMATION OF TREATMENT
1. Once your application is accepted, we will contact you with a treatment start date.
2. Admissions can be contacted toll-free at 1.877.875.8890
B. FEES FOR TREATMENT
1. Thorpe Recovery Centre is funded by Alberta Health Services (AHS), Saskatchewan Health Authority
(SHA), and private entities.
i. AHS: Treatment fees for Medically Supported Detox and Residential Treatment are covered
by AHS.
2. SHA: Treatment fees for Medically Supported Detox are covered by SHA.
3. Private: Please speak with admissions regarding fees and payment options.
C. Payment for any fees is due upon admission and can be paid by cash, debit, certified cheque, money order, e-
transfer, VISA or MasterCard. All fees are non-refundable.
D. TRANSPORTATION
1. Clients are responsible to arrange and pay for their transportation to and from the Thorpe Recovery
Centre. Taxi service is available to/from the Lloydminster Airport or the City Centre to the facility in
Blackfoot.
2. There is ample parking on site, but vehicle keys will be stored with other restricted items until discharge
during regular business hours.
E. PROGRAMMING SCHEDULE
1. Programming runs 7 days a week. Clients are required to attend all mandatory programming which will
be indicated on the schedule upon arrival.
F. ABSTINENCE PRIOR TO TREATMENT & DRUG SCREENING
1. Medically Supported Detox: No sobriety required; 24 hours preferred.
2. Residential Treatment: A minimum of 7 days without gambling, using alcohol or drugs, including
restricted medications is required. Clients must pass a drug and alcohol screening at time of admission;
a positive test will require completion of detoxification before transitioning into the 42+ day program.
Should detox be necessary at time of arrival for Residential Treatment, a detox bed at Thorpe Recovery
Centre may not be available and alternate accommodations will be required by the client.
3. We recommend speaking with your doctor regarding your plan to stop using drugs and/or alcohol as
you may experience withdrawal symptoms.
G. ABSTINENCE DURING TREATMENT
1. All clients attending programming must refrain from gambling, using drugs and/or alcohol during
treatment.
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2. Use of restricted activities or substances (including medications) will result in immediate discharge from
programming. You will be tested upon admission and periodically during your treatment as determined
at the discretion of the organization. Testing may include breathalyzer and/or urine specimen testing.
G. APPOINTMENTS & DAY PASSES
1. Legal, medical, and self-care appointments are to be made outside of the treatment period.
2. Other than for scheduled recreational activities under the supervision of a Thorpe Recovery Centre
team member, leaving the premises is considered refusing treatment (walking from program.)
3. Day passes or absences are not permitted during treatment.
H. MEDICATIONS & SUPPLEMENTS
1. All medications, including vitamins and supplements, must be approved prior to admission by
completing the pre-admission medical and submitted with the admission package. Medications must
be in pharmacy blister-packs (preferred) or original packaging, with original labels, and must match
your pre-admission medical.
2. A list of restricted medications and other substances is enclosed. If any restricted medications or
substances are brought onsite, it will be disposed of and not returned to the client.
I. ALLERGIES
1. Nuts, soy, eggs, wheat, and other allergens are used on site. Please advise admissions if you have
any environmental or food allergies. We will do our best to accommodate; however, cross
contamination may occur.
2. Thorpe may not be able to accommodate those with life-threatening allergies.
J. TOBACCO & SCENT-FREE FACILITY
1. Smoking is permitted in a designated area outside during set times. Failure to comply with these
regulations may result in discharge from programming.
2. E-cigarettes (vaping) are not permitted to be used inside the building and are used during designat
ed
s
moke breaks only.
3. Chewing tobacco is not permitted.
4. All tobacco products including vapor juice for e-cigarettes must not be open; bring enough sealed
packages or containers of cigarettes or e-liquid containers for your entire stay or make arrangements
for products to be dropped off.
5. Staff cannot purchase cigarettes or any other tobacco product for clients.
Assistance is available if you wish to quit smoking during your treatment. Not all tobacco products are
permitted on site. See the enclosed for more information.
6. Perfumes, colognes, and other scented products are not permitted.
K. MOBILITY
1. The majority of the facility is level, with exception to some optional client areas that require 4-5 steps.
2. There are accessible rooms for those with mobility devices or needs.
3. Clients are required to perform light chores during programming and will be assigned with the client’s
mobility in mind.
4. Clients are required to participate in recreational activities to the best of their ability. Injuries, mobility
and any other limitations will be considered and alternative activities may be accommodated in
coordination with the medical team.
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L. TEAM COMMUNICATION
1. Thorpe upholds confidentiality and privacy regulations. Client information in the course of treatment
planning and service delivery will be discussed and shared by the staff at Thorpe Recovery Centre.
M. VISITATION
1. Visitation is not permitted for those in Medically Supported Detox.
2. Residential Treatment clients who have been in programming for at least 2 weeks may be permitt
ed
v
isitors. All visitors must be approved by the client’s counsellor no later than the Thursday prior to the
visitation day. Visitations occur each Sunday from 1pm to 4pm in open community areas at the Centre.
Visitors cannot smoke with clients or access closed rooms.
3. Additional visitor guidelines can be found in the Client & Family Handbook.
N. DRESS CODE & FOOTWEAR
1. Firm-soled shoes are to be worn at all times. This ensures the safety of clients in the event of an
emergency or disaster.
2. A dress code is enclosed to ensure the health and safety of all. Pajamas or loungewear are only
permitted within dorm rooms for sleeping.
3. Visitors are required to abide by the dress code as communicated in the Client & Family Handbook.
Failure to comply will result in refusal of entry into facility.
O. PHONE ACCESS
1. Phone messages will not be accepted.
2. Each Residential Treatment client is permitted two 15-minute personal calls per week. A long-distance
phone card is required for all personal calls.
i. Clients who are participating in Medically Supported Detox or Transition, regardless if they are
going into Residential Treatment afterwards, are not granted personal calls until they begin th
e
42+
day program.
3. Calls regarding urgent financial, legal, or other business matters may be accommodated by the client’s
counsellor.
P. MOBILE PHONES & ELECTRONICS
1. Any electronics, including mobile phones, tablets, laptops, smart watches, and audio devices will be
itemized and stored in safe keeping until discharge from treatment during regular business hours.
2. Alarm clocks (without radio) are permitted.
Q. RESTRICTED ITEM SAFE KEEPING & LOCKERS
1. A thorough search of all belongings, baggage, and a personal pat-down will occur at time of admission.
2. Luggage and any restricted items will be stored for the entirety of treatment.
3. Non-illicit or harmless items will be returned to the client at time of scheduled discharge during regular
business hours.
4. Illicit or harmful items will not be returned to the client.
5. A locker will be provided for the safekeeping of cash, cigarettes, and any other items the client may
access during treatment.
6. T
horpe Recovery Centre is not responsible for lost or stolen jewellery, money, or other items.
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V6. Updated October 1, 2020
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Contract of Services
A. SERVICE PHILOSOPHY
1. Our services are abstinence-based; however, may be administered to assist with withdrawal symptom
mitigation including opioid agonist therapy (OAT).
2. Treatment is focussed on the therapeutic community model featuring self-help principles, group
counselling, cognitive behavioural therapy, and case management.
3. We understand that as individuals our treatment pathways will differ and we strive to ensure each
treatment plan is executed in a safe and supported manner for each person.
4. TRC’s mission, vision, and values form the core of our medically supported detox program as well as
our residential programming which is delivered in a community model with a focus on group therapy
and follows 12-step based programming.
i. Our Mission: To be a leading, community-based organization that provides strength, hope, and
healing to those affected by addiction and mental health needs.
ii. Our Vision: Together we improve lives through overcoming addiction and mental health
concerns.
iii. Our Values are: Accountability, Respect, Safety, Communication, and Integrity
B. QUALIFICATIONS OF THORPE RECOVERY CENTRE
1. Accredited with Accreditation Canada.
2. A licensed Residential Addiction Treatment Centre under the Mental Health and Addiction Services
Protection Act of Alberta (MHSPA 10000021).
3. A non-profit society incorporated in the provinces of Alberta and Saskatchewan under the name Walter
A. “Slim” Thorpe Recovery Centre Society.
4. A registered charity with the Canada Revenue Agency (108189093 RR0001).
5. Directors, program managers, community managers, nurses and counsellors have at minimum a
bachelor’s degree in the helping profession and/or related professional experience and training.
6. Clinical team members are registered with their appropriate Professional Colleges.
7. Additional community supports may be employed for referral and optional onsite services.
C. ASSESSMENT FOR TREATMENT
1. Assessing one’s fitness for treatment is based on the submitted application form, medical form, and
assessment interviews.
2. Should the services at Thorpe Recovery Centre not be in the best interest of the client, alternative
services will be discussed.
D. DESCRIPTION OF SERVICES
1. Confirmation of services rendered will be reflected in the Fee Schedule.
2. Medically Supported Detox: A 7+ day program that provides withdrawal mitigation strategies to assist
in the detoxification of drugs and/or alcohol. Should the applicant require detox at time of arrival for
Residential Program, the treatment plan will be adjusted accordingly. Participation in sessions and
assignments is required, once the client is physically able.
3. Residential Addiction Treatment: A 42+ day program that involves individual treatment planning and
group activity to provide a holistic approach to recovery. Includes a 4-day assessment period for
treatment planning purposes.
4. Continuing Care: a three-month program offered to Alumni of the Residential Addiction Treatment
program. A further commitment of six or more months is recommended. Continuing Care is a
PART I – RAT Application
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commitment of weekly peer-led virtual support groups; those in urban centres may referred to a
partnering agency for programming.
5. Clients are expected to participate in process groups and complete assignments within their
treatment plan. Additional activities such as recreation, community meetings, educational lectures
and chores are also mandatory. Failure to attend or participate may result in termination of
therapeutic relationship with the centre.
E. BENEFITS AND RISKS
1. Choosing to seek treatment is a positive step towards living a life in recovery. After programming,
individuals should have a better understanding of their actions and their needs and will have a plan to
progress.
2. Although there are significant benefits to treatment, individuals may experience uncomfortable
t
houghts, feelings or triggers, or troubling memories during the process. The Thorpe community will
support each individual through these difficult experiences as best as possible.
F. AMENITIES
1. Thorpe Recovery Centre is located on an acreage outside the hamlet of Blackfoot, AB.
2. The facility has a surveillance camera system and staffing 24/7 to ensure safety and security.
3. A fitness centre, gymnasium and outdoor spaces are accessible during specified times.
4. Recreational activities are incorporated into the mandatory treatment program and may include yoga,
crafts, music, or sports.
5. Laundry facilities are on-site. Detergent and fabric softener is available for purchase.
6. Telephone access is limited; a calling card is required. There is no internet access or use of internet-
capable devices.
7. A canteen is on site for sundry items: recovery books, sobriety coins, craft supplies, confectionary,
toiletries, and clothing.
G. ACCOMMODATION
1. All accommodations are shared:
i. Detox: Up to 3 individuals per room with a shared bathroom with tub and/or shower.
ii. Residential Addiction Treatment: 2 individuals per room with a shared bathroom with t
ub
and/
or shower.
iii. Accessible rooms are available for those with mobility devices.
2. All linens including towels are provided.
3. Clients are required to wash their own linens at least weekly.
4. Clients are required to clean their dorms and washrooms; dorm inspections are performed daily t
o
ens
ure tidiness.
5. Clients are required to perform light-duty chores that contribute to the greater wellness of t
he
c
ommunity.
H. MEALS
1. Three meals are provided daily with access to healthy snacks throughout the day.
2. Clients may not bring in their own food or snacks, nor can they be dropped off during visitation.
A
c
onfectionary is available during weekdays in the Canteen.
3. Food cannot be stored in dorms. Food and drinks may only be consumed within the dining room.
4. Clients must notify admissions of any allergies. Nuts and other allergens are used on site; therefore,
cross contamination may occur.
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V6. Updated October 1, 2020
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I. FEES
1. Clients are responsible to coordinate payment of fees.
2. Fees are due on day of admission unless otherwise arranged.
3. Thorpe Recovery Centre will assist where possible to aid in the fee procurement process, wher
e
appr
opriate.
4. Clients are responsible for sundry items such as long-distance phone cards, toiletries, transportation,
and incidentals.
5. Fees are payable by e-transfer, cheque, cash, debit, MasterCard or Visa.
J. REFUNDS
1. Incomplete Programming: It is the understanding of both the undersigned and the Thorpe Recovery
Centre that the client intends to complete the program(s) prescribed. However, there ar
e
ci
rcumstances that may result in an early discharge or incomplete services from the Thorpe Recovery
Centre including:
i. Medical Discharge: The client’s health and/or well-being significantly changes and is
beyond the scope of practice of the staff of Thorpe Recovery Centre and the client is
transferred to a medical facility or medical professional.
ii. Walk or Policy Discharge: The client, on their own will, has decided to terminate th
e
t
herapeutic relationship with Thorpe Recovery Centre, resulting in discharge from t
he
f
acility. These actions include unauthorized departure of the premises, the refusal of
services, lack of participation, breaking facility rules, and infringement of contracts.
2. In the event of incomplete services for an AHS or SHA funded bed, the client-paid amounts not
covered by the funding agency will not be refunded.
K. CONCERNS & FEEDBACK
1. Any client who may have a concern or feedback should address the issue directly with the staff member
involved.
2. Should the concern remain unresolved, the client may approach any manager for further discussion.
3. If the concern continues to be unresolved, the client may request to speak with the Clinical Director for
resolution who may involve the Chief Executive Officer if necessary.
4. All decision making will use the Ethical Decision Making guidelines and will be in alignment with the
organization’s mission and vision.
L. EMERGENCY CONTACT
1. I authorize the Thorpe Recovery Centre to contact the person(s) identified as “Emergency Contacts” in
this admission package in the case of a critical incident, emergency or unscheduled discharge from the
program. The information released will include the client’s name, date and time of the discharge,
reasoning for discharge, and if a medical emergency, where the client has been transported. I
understand that a voice mail message will be left should direct contact cannot be made.
M. SUBSTITUTE DECISION MAKER
1. A substitute decision-maker (SDM) is a person one chooses in advance to make health care
decisions for you in the event you cannot make them for yourself. If you have an SDM, please ensure
they are identified in this admission package. Learn more about SDM here:
https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=aa114475
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V6. Updated October 1, 2020
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N. SAFETY & SECURITY
1. Indoor and outdoor areas of the facility are monitored by a video monitoring system.
2. Safety checks will be performed by Thorpe team members at intervals throughout the day and night.
Client dormitories will be entered during these checks.
O. DISCHARGE
1. Scheduled discharges, for those who have successfully completed programming, are required to
at
tend morning programming, then may depart the facility after 10:30am.
2.
Unscheduled discharges, for breach of policy or by the will of the client, may occur at any time.
ii. I
tems that are left at the Centre for more than 30 days after the discharge date will be
di
sposed of.
P. CODE OF ETHICS
1. Our team is bound to a code of ethical conduct that maintains the best interest of the client. The
therapeutic relationship between Thorpe and the client remains in tact for a minimum of one year after
the completion of programming. As such, romantic or platonic relationships between staff and clients
are not permitted during this time, including non-recovery related activities in person or throug
h
t
echnology.
2. We understand that special bonds may develop between those in programming at the same time;
however, to respect each person’s own boundaries, romantic or sexual relations between individuals
will not be permitted and will be addressed by the Thorpe team.
Q. PERSONAL INJURY OR AILMENT
1. I release the Thorpe Recovery Centre from personal injury should I choose to use any equipment
provided to me during my programming the Centre.
2. I release the Thorpe Recovery Centre from any damage or loss of property during my programming
at
the Centre.
3. I release Thorpe Recovery Centre from any and all liability in relation to my participation in any and all
aspects of the programming.
R. LIMITS OF CONFIDENTIALITY
1. I understand that my treatment and any information I may share with Thorpe Recovery Centre is
confidential and that any release of information shall require a signed release from me.
2. I further understand the following limits of confidentiality. Thorpe Recovery Centre staff may release
pertinent information to the appropriate authorities including, but not limited, to police officer, RCMP,
medical personnel, the Child and Family Service Authority, without a signed release in the following
circumstances:
i. If I disclose that I have intentions of harming myself.
ii. If I disclose that I may cause harm to someone other than myself.
iii. If I disclose that a child or elder is in imminent risk of being abused or harmed.
iv. If subpoenaed by the court, the Thorpe Recovery Centre is legally required to make my file
available to the judicial system.
S. MUTUAL RESPECT AGREEMENT
1. All clients and employees of Thorpe Recovery Centre have the right to a safe, secure and violence-
free environment. Thorpe recognizes this right and acknowledges that nothing is more important than
the safety and security of its employees and residents.
PART I – RAT Application
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2. Thorpe Recovery Centre is committed to providing an atmosphere that is free from abusive
behaviour, acts of violence or threats of violence. In keeping with this commitment, Thorpe Recovery
Centre has established a policy that provides “zero-tolerance” for actual or threatened violence
against clients, co-workers, visitors or any other persons who are either on our premises or have
c
ontact with clients and employees in the course of their duties.
3. We define abusive behaviour and violence as actions or words that endanger or harm another
person or result in people having a reasonable belief that they are in danger. Such actions include:
i. Verbal, sexual or physical harassment
ii. Verbal, sexual or physical threats and intimidation
iii. Assaults or other acts of violence or indecency
4. Reports of violence will be investigated, and may receive a consequence in a manner deemed
appropriate by staff which may result in discharge from program.
5. All personal information shared by others during programming or otherwise while in the care of Thorpe
Recovery Centre is not to be discussed outside of the building.
6. Gossip or hearsay between clients and/or staff will not be tolerated.
I understand that treatment information is recorded in my client file for reference and that Thorpe
Recovery Centre staff and associates share information among relevant team members to assist in the
delivery of services.
I will participate in all mandatory programming to the best of my ability. I agree to adhere to the rules and
policies set out by the Thorpe Recovery Centre and understand that failure to do so will result in
termination of programming.
I agree to all of the terms and regulations set out before me in the Conditions of Admission and Contract
of Services.
C
lient Name: __________________________________________ DOB: ______________________
Client Signature: __________________________________________ Date: ______________________
Witness Signature: ________________________________________
Date: ______________________
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Applicant Information
GENERAL INFORMATION
Legal Name: __________________________________________________________________________________________
Last First Middle
Preferred Name: _____________________________________ Alias:____________________________________________
Address:_____________________________________________________________________________________________
PO Box/Suite Street Address City Province Postal Code
Phone Number: ___________________________________ Alternate Number: ____________________________________
Email Address: ________________________________________________________________________________________
Gender: Male Female Transgender Other: ________________________________________
Ethnicity: _____________________________ Aboriginal Ancestry: No Yes: Status #: _________________________
Date of Birth: (YYYY/MM/DD) _______________________________________ Current Age: _________________________
Provincial Health Number: _________________________________________ Province: ____________________________
Medical Benefits # (if applicable) _____________________________________ Carrier #: ____________________________
Group or Plan # __________________________________________________ Certificate / Member #:__________________
How did you hear about the Thorpe Recovery Centre? _________________________________________________________
Do you have any relationships – personal or otherwise, with any TRC staff? No Yes: _________________________
EMERGENCY & SUBSTITUTE DECISION MAKER CONTACT INFORMATION
Emergency Contact:
Name: ____________________________________________ Relationship: ______________________________________
Address:_____________________________________________________________________________________________
PO Box/Suite Street Address City Province Postal Code
Phone Number: ___________________________________ Alternate Number: ____________________________________
Email Address: ________________________________________________________________________________________
Substitute Decision Maker: Same as Emergency Contact
Name: ____________________________________________ Relationship: ______________________________________
Address:_____________________________________________________________________________________________
PO Box/Suite Street Address City Province Postal Code
Phone Number: ___________________________________ Alternate Number: ____________________________________
Email Address: ________________________________________________________________________________________
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REFERRAL SOURCE INFORMATION
Self/Family AHS Addiction & Mental Health SK Addiction & Mental Health Child Welfare
Physician/Hospital Other Community Mental Health & Addiction Support
Employer/ EAP Legal/Justice System/Drug Court Other: ________________
Referral Source Name: _________________________________ Agency: _________________________
Phone: ______________________________________________ Fax: ____________________________
Email: ___________________________________________________________________________________________
EMPLOYMENT
Current Employment Status: Unemployed Employed Retired Disability Homemaker
Student
Length of Current Employment Status _______ Occupation ___________________________________________________
EDUCATION
What is your highest level of completed education? Gr. 1 – 9 Gr. 10 – 12 Some Post-Secondary
Post- Secondary Trade Certificate
Do you have a learning disability? ADHD Comprehension Processing Deficits
Reading Non-Verbal Writing Other: _____________
FAMILY AND SOCIAL HISTORY
What is your partnership status? Married / Common Law Single Separated Divorced Widowed
What is your sexual orientation? Heterosexual Homosexual Bisexual Other: ______________
Do you have any concerns regarding your relationships or non-relationships? Please explain:
Do you have children? No Yes (please list, attach additional pages if necessary):
Name
Age
Sex
Does this Child Live With You?
No Yes
No Yes
No Yes
No Yes
Do you have any concerns regarding your relationship with your children? Please describe your concerns
Please list all of your support systems (i.e. 12 step, family, friends, church, community agencies etc.)
HOUSING
Are you currently homeless? No Yes:
With whom are you now living with ____________________________ for how long? _____________
Do you currently live with anyone who has an addiction issue? No Yes
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ADDICTION INFORMATION
Which of the following have you experienced because of your alcohol, drug use and/or process addiction use? Please check all
that apply.
Blackouts
Inability to stop drinking, acting out or using once you start.
Feelings of guilt.
Increased tolerance of alcohol, drugs and/or process addictions.
Drinking or using in the morning.
Previous attempts to stay sober or clean followed by a return to drinking, using and/or process addictions.
Hospitalization due to use of alcohol, drugs and/or process addictions.
Advised by a physician or other health professional to stop or reduce drinking, using or acting out.
Which of these employment/school issues have you experienced in the past? Please check all that apply.
Absenteeism
Drinking, using drugs and/or process addictions at work or school.
Resigning work or dropping out of school as a result of your alcohol, drug use and/or process addictions.
Disciplinary action
Concern about performance
Attending work or school under the influence of alcohol, drugs and/or process addictions.
Please identify how addiction has affected these areas of your life:
Family
Emotional Well-being
Social Well-being
Physical Well-being_
Spiritual Well-being_
Finances
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ADDICTION HISTORY
Please list substances used (past and present) including drugs, alcohol, solvents, prescriptions, over the counter medications,
and behaviours. Use an * to indicate your primary addiction and ** for your secondary: Attach additional pages if required
Substance Amount Used Daily/Weekly/Monthly Date of Last Use Age of First Use
Considered
Have you ever been affected by the alcohol/drug use, gambling and/or process addictions of family members?
No Yes (describe): _______________________________________________________________
GAMBLING & GAMING HISTORY
Which types of gambling (past and present) have you participated in?
VLT Pro-line Track Bingo Casino Virtual Gaming
Online Poker Card Games Games of Skill Lotteries Other: ___________
How long have you been playing the above game(s) and how often do you gamble? __________________________________
How long have you recognized gambling as problem? _______________________________________________
What are your main concerns about your gambling at this time? _______________________________________
OTHER HISTORY
Do you identify any of these behaviours as being problematic? Internet Use Relationships Shopping Sex
Food Other: ___________________________
If you checked yes for food, would you describe it as an eating disorder? No Yes (explain):
Have you ever experienced a time when food controlled you or interfered with your life? No Yes
Have you ever tried to abstain from any of the above activities? No Yes
Has anyone ever expressed concern about your involvement in these activities? No Yes
TOBACCO USE
Do you currently use tobacco or nicotine products? If yes, complete the following:
Do you currently smoke cigarettes? No Yes
If yes, are you interested in quitting? No Yes
How many cigarettes do you smoke daily? 5 or Less 5 – 10 10—20 More than 20 (1 pack)
Do you currently use an e-cigarette/vape? No Yes
If yes, are you interested in quitting? No Yes
Do you currently chew tobacco? No Yes
If yes, are you interested in quitting? No Yes
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TREATMENT AND DETOX
Is this your first time accessing any form of treatment? No Yes
Have you previously accessed or received treatment at Thorpe Recovery Centre? No Yes
Date(s) _______________________________ Did you complete the program? No Yes
Have you previously attended detox/or residential programming at another centre? No Yes
If yes, where? _________________________________ When? ____________________________
Did you complete? No Yes Reason: ____________________________________
TRAUMA/LOSS
Have you experienced any of the following types of abuse/trauma?
Sexual Abuse Physical Abuse Emotional Abuse Domestic Violence Other: ______________
Have you experienced any of the following types of significant life losses?
Death Health Problem/Change Divorce/Separation Loss of Job/School
Other: ______________________________________________________
Are you experiencing any of the following concerns?
Problems with Family Housing Problems Problems with Social Environment
Financial Problems Educational Problems Problem with Access to Health Care
Occupational Problems Legal Problems Other: ________________________
LEGAL HISTORY
Do you have any of the following issues: Parole** Probation** Bail**
Incarceration (Including Remand) House arrest
Conditional Sentence Non-Contact Order
Child & Family Orders
Do you have any past charges? No Yes (explain): ___________________________________
Do you have any outstanding legal charges? No Yes (explain):
Charge(s): ________________________________________________________________________________________
Upcoming court date(s):______________________________________________________________________________
Do you have any other legal issues? No Yes (explain): ____________________________________
**Probation Officer or Bail Supervisor Name: _________________________________________________________
Phone Number: ___________________________ Email:_____________________________________________
Legal Counsel: _______________________________________________________________________________
Firm: _________________________________________ Phone Number: ____________________________
MEDICAL HISTORY
Primary Physician: _____________________________________________________________________________________
Address:_____________________________________________________________________________________________
P
O Box/Suite Street Address City Province Postal Code
Office Phone: ____________________________________ Office Fax: __________________________________________
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Have you had any medical conditions/illnesses within the past two years? No Yes If yes, identify:
Are you taking any prescription medications or over-the counter medications? No Yes
If yes to either, please list (attach additional sheets if required):
All medications must be handed over upon intake; only authorized prescription medications in original packaging or blister-packs
will be admitted and returned to the client upon discharge.
Any medications or substances that are not approved and/or not in original prescription packaging will be destroyed.
Have you been hospitalized in the past year? No Yes (describe):
Known allergies (environmental, food, medication, etc.): No Yes (describe):
Do you have any special dietary requirements (cultural or intolerances)? No Yes (describe):
Do you have any issues that require accommodation? (hearing loss, mobility etc.) No Yes (describe):
Do you have trouble with sleeping?: Apnea Staying Asleep Falling Asleep Night Terrors
Snoring Sleepwalking
Are you affected by any of the following?: HIV/AIDS Hepatitis Scabies Lice Bed Bugs
PSYCHOLOGICAL AND MENTAL HEALTH INFORMATION
Are you currently seeing a mental health professional? No Yes (specify):
Psychiatrist Psychologist Therapist Other: _______________________________________________
Name: ______________________________________________ City:_____________________________________
Phone: ___________________________________ Email: ______________________________________________
Do you have a current formal mental health diagnosis? No Yes (specify):
When, and by whom? _______________________________________________________________________________
ADD/ADHD Anxiety Disorder Bipolar Borderline Personality Disorder
Depression Dissociative Disorder FASD OCD PTSD
Schizophrenia Other: ______________________________________________________________________
Name of Medication
Dosage/Frequency
Duration of use
Reason taken
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Do you have a past mental health diagnosis? No Yes (specify):
When, and by whom? _______________________________________________________________________________
If yes, please check all that apply:
ADD/ADHD Anxiety Disorder Bipolar Borderline Personality Disorder
Depression Dissociative Disorder FASD OCD PTSD
Schizophrenia Other: ______________________________________________________________________
Have you had any suicidal thoughts or attempts in the past year? No Yes (specify):
When: _____________________________ What happened: ___________________________________________
Do you currently have any suicidal thoughts or are planning an attempt? No Yes(specify):
What is your plan: _____________________________________________________________________________
Do you have any history of self-harm behaviours? No Yes (specify):
Have you received or inquired for help with this? No Yes (specify):
With Who: ___________________________________________________________________________________
What is your plan: _____________________________________________________________________________
GOALS
What are your goals for treatment?
This Applicant Information was completed by:
Self- Referral (includes Family Members)
Referral
Referral Source Name: ____________________________ Agency: _________________________
Phone: _________________________________________ Fax: ____________________________
Email: ____________________________________________________________________________________
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Pre-Admission Release and Collection of Confidential Information
The following allows our team to connect with those who have helped you on your recovery journey so we may
best assess your needs. Upon arrival at Thorpe Recovery Centre, you will have the opportunity to identify
additional individuals and agencies who may know about your stay at the Centre and other aspects of your
treatment.
I, ___________________________________________, permit the Thorpe Recovery Centre to contact the
persons and agencies listed below to collect and/or release information pertaining to my medical history:
WHO MAY BE CONTACTED
Psychiatrist, Physicians, Addiction & Mental Health Counsellors, Nurses or Pharmacists who have been consulted
within the last 6 months or while the I have been in treatment at Thorpe Recovery Centre:
INFORMATION PERTAINING TO
To release verbally or in writing:
Discharge Summary (includes):
• Assessment and Treatment Planning
Information
• Progress Reports
• Continuing Care
• Confirmation of Attendance/
Completion & Dates of Treatment
• Legal Status
• Medical Status and Information
Financial Status
Change in Treatment Plan /
Termination of Treatment
Emergencies
Other (specify): ________________
To collect verbally or in writing:
Assessment
Attendance
Relevant History
Progress Summary
Reason for Referral
Medical Information
Legal Status / Conditions
Treatment Summary
Employment History
Service Monitoring
Other (specify): ________________
GRANTING CONSENT
I understand that provision of treatment services is not dependent on my decision to release information and that I
may cancel this consent at any time. I understand that some action may have been taken prior to any cancellation.
Release Expiry Date: ______________________________________
Client Name: __________________________________________ Date: ______________________
Client Signature: __________________________________________
Witness Signature: ________________________________________
CANCEL CONSENT
I cancel the above permissions prior to the expiry date. I understand that some action may have been taken prior
to this cancellation.
Client Name: __________________________________________ Date: ______________________
Client Signature: __________________________________________
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Packing Checklist
WHAT TO BRING:
One suitcase and one backpack.
Two pieces of ID (one photo ID), Provincial Health Care card or number, and benefits provider/card info.
All approved medications in blister-packs. Quantities should last the extent of your programming.
Earplugs or a white noise machine (for light sleepers)
Personal hygiene items. Scented or alcohol based products are not permitted.
Pillow (optional).
Reading material for free time (e.g., 12-Step or other recovery reading material). Books will be reviewed by
TRC staff for treatment appropriateness. Books with violence, sexual content, or substance use will not be
permitted.
Clear water bottle and/or clear travel mug with a lid.
Pen and paper or journal
Casual, modest and comfortable clothing, weather appropriate clothing, outdoor walking shoes and indoor
footwear; fitness wear for use in gym and fitness centre (t-shirts, shorts, track pants, clean running shoes
with non-marking sole); sleepwear (must be worn in event of emergency or dorm checks); modest
swimwear and towel for recreation (this activity is optional and not always available).
Money for incidentals (bring small bills or coins as change is limited). There is an ATM on site. Do not bring
more than $200 in cash.
Alarm clock or watch (without a radio) if you need one. Smart Technology is not permitted.
WHAT NOT TO BRING:
More than 1 suitcase and 1 backpack.
Electronic or internet-capable equipment including: clock radios, cell phones, tablets, laptops, stereos,
video games, TVs, mp3 players, smart watches, or electric blankets.
Tobacco products other than cigarettes, including tobacco and products with alcohol dipped flavors, and
chew tobacco. Cigarettes or e-juices in open containers are not permitted (must arrive new/sealed).
Revealing clothing and apparel suggestive of violence, alcohol, drugs, gambling, sex or discrimination.
Leggings must be worn with a top that will cover to mid-thigh.
Food, candy, or drinks, including weight altering substances or meal supplements.
Scented products or products containing alcohol, hemp, CBD or scents including: perfume or cologne;
mouthwash; nail polish or polish remover; aerosol hairspray; essential oils, strong smelling lotions, etc.
(Alcohol-free mouthwash and hair products are allowed).
Weapons (including pocketknives), compact mirrors/mirrors or valuable jewellery.
Drug paraphernalia, gambling paraphernalia, pornography and sexual toys/aids.
Herbal remedies.
I have read the above list and agree to only bring the approved items. I understand that my personal
belongings will be searched and I will have a personal search and pat-down upon arrival. If I arrive at
Thorpe Recovery Centre with items that are not allowed or have additional items beyond the limit of 1
suitcase and 1 backpack, I understand that I may not be admitted to the program and/or the restricted
items will be confiscated.
Client Name: __________________________________________ Date: ______________________
Client Signature: __________________________________________
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Information for Client Support Network
D
ear Friends, Family, and Employers;
We appreciate that you are concerned about how your loved one is doing while with us at Thorpe Recovery
Centre (TRC). We know that you may be eager to speak with the counsellors, nurses, or support staff at the
Centre in regards to the wellbeing of your loved one. At TRC, we have our own code of ethical conduct and we
also abide by the Freedom of Information and Protection of Privacy Act as well as the Health Information Act.
Among all of these regulations and guidelines are strict rules about who is and who is not entitled to a client’s
protected personal information. To ensure a safe and trusted environment, we ask for your cooperation and
understanding of our confidentiality policies. This letter will help you understand:
1. The types of information that are protecte
d
2. Com
munication and information you can expect from TRC
PROTECTED PERSONAL INFORMATION
Some examples of protected personal information of clients who seek professional healthcare include:
1. Physical and psychiatric diagnoses
2. Medications prescribed (if applicable)
3. Reports and clinical notes
4. Recommendations for further testing
5. Disclosures in assessments or therapy, and
6. Certain details in the therapeutic process.
According to the regulatory laws, codes of ethics, and policies, even the funder is not entitled to a client’s
protected personal information.
Of course, there may be times when it is important for families to have a better understanding of their loved one’s
condition. For example, perhaps the clinical team discovers a client has dementia and needs help making
decisions. In this case, we decide if it is in the client’s best interest to inform a family member of the new
diagnosis. Cases like this are exceptional.
CLIENT’S WRITTEN PERMISSION
When a client gives us written permission to speak with their family, this does not mean that we can reveal their
protected personal information. It does mean that we can discuss, for example, whether the client is still at TRC,
their general progress, and certain recommendations to support them in life after treatment. On rare occasions, a
client does not give us permission to talk to families. While we do work with the client to understand why they
refused consent, we are obligated to adhere to their wishes. Although it is difficult for families and TRC staff, we
are obligated to avoid contact. For example, if you were to call us, we would reply, “I’m sorry but I can neither
confirm nor deny that such person is here.” Other professionals who provide care to your loved one, such as a
psychiatrist in their hometown, may benefit from knowing the clinical details of the client’s experience at TRC. In
this case, we follow standard practice by obtaining a signed consent to provide information to the specific
professional.
WHAT YOU CAN EXPECT
If you are on the Release of Information, within the first few days of the client’s stay at TRC, your loved one’s
Primary Counsellor will contact you to let you know how the client is settling in, with respect to the client’s wishes
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on the release of information. The Primary Counsellor will address questions and concerns you have throughout
the treatment period and may ask questions of you as well to help further develop the treatment plan. Additional
information regarding our programming expectations can be found in the Client & Family Handbook, which can be
found on our website.
FAMILY INTENSIVE
The Primary Counsellor will also let you know about the Family Intensive and encourage your participation. If
you’re interested in attending our Family Intensive, a member of our team will contact you regarding registration
and program dates.
The Thorpe Recovery Centre’s Family Intensive is designed to help families learn new ways to live with addiction
in their lives, regardless if your loved one is in a treatment program or not. It further provides friends and family
with an opportunity to enter into their own journey of healing and begin to experience hope and recovery.
THE THERAPEUTIC RELATIONSHIP
Your loved one at TRC will develop what we call a “therapeutic relationship” with the clinical team. This
relationship is important and it is also protected by the laws of Alberta. The purpose of protecting the relationship
is to help your loved one feel free to disclose emotionally charged feelings and issues, without having to worry
that we will tell friends, employers, and family. Trust is essential. Under these acts and codes of ethics, our clinical
team see the clients as their primary responsibility, including protecting confidentiality. As a result, there is an
obvious distinction between how they work with clients and how they work with family members.
In the event of a Medical Discharge or Walk the Emergency Contact will be notified.
DIRECT COMMUNICATION WITH YOUR LOVED ONE
Your loved one is entering treatment at the Thorpe Recovery Centre to focus on their own health and wellness.
Systems of communication and technology can be distracting and inhibit one’s personal growth, which is why
TRC does not provide internet access to clients, unless supervised for business or financial purposes.
For contact, clients are entitled to two (2) outgoing 15-minute phone calls per week. Clients cannot accept calls
nor will messages be taken by reception. Please forward any messages or inquiries to your loved one’s Primary
Counsellor who can be contacted by email or by phone to 780-875-8890.
Individuals who are participating in Medically Supported Detox or in their Transition phase into Residential
Treatment are not granted personal telephone access.
Clients are also encouraged to write and receive letters. All mail can be sent to:
Client’s Name
C/O Thorpe Recovery Centre
PO Box 291, 21060 Tranquility Way
Blackfoot, Alberta T0B 0L0
Please note that all letters, parcels, and dropped-off packages will be searched upon receipt.
We encourage you to download our Client & Family Handbook from our website to learn more. Visit
www.thorperecoverycentre.org/admissions to get your copy.
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SUPPORTING YOUR LOVED ONE
Entering treatment can be a time of great opportunity as well as anxiety for your loved one. As such, people with
addictions may fluctuate in their commitment toward recovery.
For example, some individuals may not fully grasp the severity of their chemical dependency or process addiction
or may deny there is a problem and be resistant to treatment. Whereas others may go through a “grieving
process” over the loss of their relationship with their drug of choice. We ask family members and loved ones to
understand that such resistance or grieving—accompanied by bargaining and a roller coaster of emotions—is a
normal part of the healing process.
There will be times when the client in treatment will want to leave and we will do our best to have your loved one
focus on recovery. Bear in mind that such efforts are not always successful and clients have the right to refuse
treatment and leave the facility.
H
elpful Support
•
Understanding client’s fluctuations in their
commitment to recovery.
•
Listen and be supportive without judging.
•
Do not make hasty decisions. Stay calm and
gi
ve the treatment process time.
•
Do not assume that because a client is not
happy in treatment that they are having
problems with the style of therapy. This may
be part of a natural process of finally
accepting the addiction.
•
Do not feel like you have to rescue a client
from their own upset feelings during
treatment.
•
Give a client time and space to come to
t
erms with their own recovery program.
•
Do not try to make a client feel guilty for
being in a recovery program even if they are
unable to help out with responsibilities at
home.
•
Ask the counsellor assigned to the client if
you have any questions about the recovery
program.
•
Learn about ways to start your own healing
process by attending the Family Intensive
t
hat is offered monthly.
Unhelpful Support
• A
greeing with and supporting the upset
client without understanding the full
situation. Remember that you may be
hear
ing only the part of a story the client
wants you to know in order to justify leaving
t
reatment.
• Minimizing the addiction problem
and
ac
cepting that the client will get help at
home if they want to.
• Distracting a client from their recovery
process by asking them for constant
attention and assurance of being loved.
• Telling the client that you feel jealous about
the time that they are spending focusing
on
recovery. Remember that a client in a
r
ecovery program is working to becom
e
w
ell. Therefore, treatment is an investment
for the future.
• Assuming that a client in recovery is tryin
g
to be someone else or is under some
“
cultish” influence. Clients will learn new
words and ways of communicating as a
c
onstructive part of the recovery process.
Seek to understand the new langu
age
i
nstead of feeling concerned by suc
h
c
hanges.
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RESIDENTIAL TREATMENT PROGRAM Part I Application for Admission

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Completed 18 February 2021

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