Document Checklist

Confidential Document

GUEST Information Intake Package “A” 2007/2008

Applicants must be 19 years & older

Program Name ______Program Date ______Guest’s Name ______Guest’s Phone ______

Document Checklist Package “A” Guest Information Self-Assessment Package “B” Referring Worker’s Assessment Signed Statement of Commitment – Page 9 Signed Release of Information – Page 10 Signed Limitation of Liability – Page 11 Was this package completed with the referral worker? Y/N ___ Tsa-Kwa Luten is not wheelchair accessible Incomplete packages will not be accepted

Do you need help to complete this form? Please contact your referral worker. This Program is funded by Aboriginal Healing Foundation to provide healing programs for Aboriginal Peoples. Please Print Clearly

Last Name: First Name: Partner’s Name: (if applicable) Middle Initials: Birth date: Aboriginal Identity: Marital Status: Status Single Non-status Common-Law Age: Inuit Married Metis Divorced Sex: Other Separated Widowed  Female  Male Street Address: Mailing Address Phone Number: (COMPLETE):

Postal Code: E-mail Address: Care Card Number: Living ON or OFF Reserve:  ON  OFF First Nation Name: First Nation Address: Full Status Number: (if applicable) (if applicable) (if applicable)

Postal Code: Referral Worker’s Name: Address of Referral WorkerAlternate Referral Worker’s Organization: Name:

Type of worker: (A&D Type of worker: (A&D Counsellor/CHR/Wellness Counsellor/CHR/Wellness Counsellor/etc.) Counsellor/etc.)

Phone: Phone:

Fax: Postal Code: Fax:

Emergency Contact Peer Support Peer Support Name: Name: Name:

Phone: Phone: Phone:

Did you attend Residential School? If yes, which school? ______Did your parents, grandparents or relatives attend Residential School? If yes, which school? ______

PHYSICAL NEEDS a. Do you have any medical issues? If so, please specify. Heart Condition – Please explain: When: (angina, hypertension, surgery, pacemaker) HIV/AIDS – Special dietary needs: Cancer Seizures, Epilepsy, Neurological concerns (Please circle) FASD Diabetes – monitor blood level by Pills___ Injection___ What are your target levels (Where should your blood sugar level be?) ______Arthritis Physical impairment - vision, hearing, mobility (Please circle) Hepatitis A, B or C (Please circle) Tuberculosis ~TB Active Dormant Asthma Other Please Explain: Are you on any medication(s)? Please list. YES__NO__ Medication(s) Dosage(s) Reason(s)

Do you have any allergies to medication(s)? YES__NO__ If so, please list:______If yes, what is the level of your reaction? Mild Moderate Severe If severe, do you require medication or hospitalization? YES__NO __ If yes, please explain.

Do you have any food allergies? YES__NO __ If so, please list:______If yes, what is the level of your reaction? Mild Moderate Severe If severe, do you require medication or hospitalization? YES__NO __ If yes, please explain.

Do you have any other health conditions? YES__NO __ If yes, please identify.

Are you waiting for surgery for any health conditions? YES__NO__ If yes, what is the surgery for and when is the scheduled date?

Have you recently had surgery? YES__NO__ If yes, what was the surgery for and when was the surgery?

Are you able to walk up and down stairs? YES__NO__

Do you require bathroom or bathing aids? YES__NO__ 2. Are you pregnant? (If applicable) YES__NO__ What is your due date? ______(A letter may be required from your family doctor) 3. Do you exercise regularly? Please explain. YES__NO__

Do you require assisted daily living i.e. LPN or support worker? YES__NO__

EMOTIONAL NEEDS

Relevant past and present issues:

Sexual Abuse Low self esteem Physical Abuse Lack of trust Verbal Abuse Self-hatred Victim of rape Hatred of others Victim of gang rape Inability to express emotions Depression Emotional Abuse Anxiety Grief & loss Sexual identity Foster/adoption Abandonment Spiritual abuse Residential School Cultural oppression Boundaries Misuse of drugs Misuse of alcohol Misuse of prescription drugs Attempt of suicide When? ______Suicidal thoughts When? Eating disorder: Other

Have you participated in groups before? YES__NO__ Please describe types of experiences.

Do you feel ready and willing to participate in intensive group work? YES__NO__

4. a. Do you have difficulty identifying or expressing emotions? YES__NO__

b. Are you on any anti depressant drugs? YES__NO__ c. Are you on any anti anxiety drugs? YES__NO__ d. Are you on any mood altering drugs? YES__NO__ If yes, please list. ______e. Please tell us how you deal with anger. (Angry outbursts, yelling, storming out, throwing objects, and/or withdrawing.) ______a. Have you been diagnosed by a physician or psychiatrist for any mental illness i.e. bi-polar disorder, schizophrenia, depression? YES__NO__ (include any diagnosed disorder) bi-polar schizophrenia depression

Other ______b. If so, how are you able to stabilize this condition?

c. Do you have feelings of extreme sadness, depression, anxiety or panic attacks?

What key issues would you like to work on? (anger, grief & loss, depression, sexual abuse, low self-esteem, etc.)

Have you had a stressful life event occur? (Changes in your life: money problems, birth, death, divorce, relocation, violence, diagnosis of medical condition)

8. Please describe 3 goals you have for yourself?

C. SOCIAL SUPPORT

Who do you go to in your community for support? Please indicate below. Weekly Bi-weekly Monthly Family ______Friends ______Religious Organizations ______Cultural Organizations ______Other ______a. Is this working for you? YES__NO__

b. If no, what changes are needed to make it work? ______

D. SPIRITUAL/CULTURAL NEEDS

Which Nation are you from?

Please identify any cultural practices that help in your healing (cultural events, native healers and self-healing practices).

MENTAL NEEDS Have you attended Residential School? YES__NO__ Have your parents or grandparents? YES__NO__DON’T KNOW How has this impacted your life?

Can you identify past traumas in your life that effect your well being? ______

3. a. Have you ever attempted suicide? YES__NO__ If so, when?

b. Have you had recent suicidal thoughts (i.e. last 6 – 12 months)? YES__NO__ If so, when?

2. Do you see/attend: Weekly Bi-weekly Monthly

Therapist or Counsellor ______Alcohol & Drug Worker ______CHR or Health Professional ______Peer Support Program ______Medicine Person ______AA, NA meetings ______Group Therapy Programs ______Elder’s Support ______Other ______a. Is this support working for you? YES__NO__

b. If no, what changes are needed to make it work?

a. Is this support working for you? YES__NO__

b. If no, what changes are needed to make it work?

Have you engaged in additional healing programs since the completion of your last FNHH program?* (Treatment centre, healing circles, cultural practices, physical activities, sports, journaling, self-help books, other) YES__NO__

If not, why?

Additional Information:

______

*Please note for Guests who have attended previous FNHH Programs we strongly recommend that you have taken steps in your healing journey before commencing another program. Please describe the steps you have taken. Guest’s Name: ______(Please Print) STATEMENT OF COMMITMENT

For First Nations House of Healing At Tsa-Kwa-Luten Lodge

I understand that my participation in the First Nations House of Healing Programs at Tsa-Kwa- Luten Lodge requires that:

I remain on the grounds of the lodge for program duration.

I am clean and sober for one month or longer before attending the program. (If alcohol and/or drugs are a problem for me) If I use any substances while in the program, I understand that I will be discharged immediately. (I may reapply when free of all substances)

I commit to follow-up with my Counselor/Therapist/Referral Worker in my community upon completion.

I commit to complete a pre-evaluation and post-evaluation of the program.

I commit to attend, participate and remain in each program everyday, on time as scheduled within the program agenda.

No visitors allowed during program. (**NO EXCEPTIONS**)

I monitor my own medications and avoid the misuse of prescription drugs while in the program. (i.e. T 3’s, gravol, anti depressants, muscle relaxants)

I commit to continue my healing journey after the program is completed. I have read and understand the above statement and I will abide by them. My signature below hereby indicates that I agree to the above

______Guest Signature Date

______Referral Worker Signature Date

USE AND RELEASE OF MY INFORMATION I ______, give permission to the FIRST NATIONS HOUSE OF HEALING to speak confidentially to ______(referral worker) and obtain written confidential information from the referral worker.

All confidential information about me must remain confidential at all times and not disclosed to anyone outside of the FIRST NATIONS HOUSE OF HEALING, except in the following specific occurrence:

The FIRST NATIONS HOUSE OF HEALING will use my statistical information for reporting and descriptive data purposes. But must not use my name in any reporting and/or descriptive data findings. (Initial)

The FIRST NATIONS HOUSE OF HEALING will release necessary confidential information about me to any helping person or agency required by law:

If I have disclosed child abuse; If there is a perceived risk, by the FIRST NATION HOUSE OF HEALING that I might harm myself or others; If the information is subpoenaed to Court.

Referral Worker: ______Signature

Alternate Referral Worker: ______Signature

Date: ______

______Guest Signature Print Name Limitation of Liability

The First Nations House of Healing (FNHH) has requested that all guests in the healing programs supply all relevant medical disclosure information relating to the guest’s health, prior to the start of the program. The guest waives all right to claims against FNHH which result from the guests failure to supply this medical information and which causes the guest to suffer damages while the guest is involved in the FNHH Program(s); The FNHH accepts no liability for any damages caused to the guest where this lack of disclosure causes the guest damages and prevents the FNHH from dealing with a guest’s health problem, experienced during any of its programs.

My signature below hereby indicates that I agree to the above.

______Guest Signature Date

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Revised July 24, 2007