|
KEN BROWN RECOVERY HOME
8 Herrick Street
Sault Ste. Marie,
ON
P6A 2T4
APPLICATION FOR ADMISSION
NAME
_____________________________________ DATE OF BIRTH
______/______/______
Last Middle
First Day
Month Year
AKA
(any other name) ____________________
O.H.I.P. #
_________________________________
S.I.N. # _______________________________
ADDRESS (permanent or last)
NEXT OF KIN
STREET
_______________________________
CITY
___________________________________
PROVINCE ____________________________
POSTAL CODE
________________________ COUNTY
_____________________________
TELEPHONE: HOME _________________
OK TO LEAVE MESSAGE |
NAME
_______________________________
ADDRESS _____________________________
CITY __________________________
TELEPHONE ________________________
RELATIONSHIP _____________________
WORK __________________________
HOW LONG AT PRESENT ADDRESS_______ |
|
REFERRAL AGENT:
(Organization)
CITY
______________________________________
ADDRESS
__________________________________
PHONE
____________________________________
FAX
_______________________________________
NOTE: -clients must
be substance free a min of 5 days
-Fee for service charged to clients with income
-Social assistance/FBA clients funding
discontinued while in our program.
-Medical/assessments should be faxed with
application or brought with client.
MARITAL STATUS: (check correct
box) EMPLOYMENT STATUS (current status)
o
Married
o
Employed full time
o
Student / Training
o
Single
o
Employed prt. time
o
Disabled
o
Separated/divorced
o
Unemployed (looking)
o
Retired
o
Widowed
o
Not in labor force
LANGUAGE SPOKEN
EDUCATION
FIRST LAGUAGE SPOKEN
o
English
o
French
Other________________
LANGUAGE PREFERRED
o
English
o
French o
Bilingual |
|
o
No formal schooling
o
Some primary school
o
Primary school
o
Some secondary school |
|
o
High school (completed)
o
Some College/University
o
College University
o
Other_______________
|
INCOME SOURCE
o
Wages & Salary
o
GWA
o
FBA
o
Disability pension
o
Workers comp.
o
U.I.C.
o
Retirement income
o
Other ________________
o
Unknown
LEGAL STATUS
o
No problems
o
Waiting trial / sentencing
o
On probation
o
On parole
o
Incarcerated
o
Other______________________________
Treatment Mandated
Probation/parole
Officer_______________________________________
Address___________________________________
Phone___________________________
Conditions /
restrictions
________________________________________________________________
If on probation or
parole: Date started ___________________ Date finished
_____________________
FPS
#_____________________________
PRESENTING SUBSTANCE ABUSE
PROBLEMS
Substances used
in last 30 days:
(Write
substances in order of severity) Code
Codes: fill blanks with following codes)
1st
____________________________ o
01 = did not use 04 = 3-6 times wk.
2nd____________________________
o
02 = 1-3 times wk. 05 = daily use
3rd____________________________
o
03 = 1-3 times wk. 06 = binge
Substances used in past 12 months
(check appropriate boxes)
o
None
o
Amphetamines
o
Other psychoactive drugs
o
Barbiturates
o
Glue/Inhalants
o
Cannabis
o
Alcohol
o
Cocaine
o
Hallucinogens
o
Tobacco
o
Prescription Opioids
o
Over the counter codeine
o
Steroids
o
Heroin / Opium
o
Benzodiazepams
q
Crack
q
Ecstasy
q
Undifferentiated
q
Unknown
IDU (intravenous
drug use)
o
Never used
o
Injected in past 12 months
o
Injected prior to 1 yr.
Is there a history of
substance abuse in your family?
__________________________________________
___________________________________________________________________________________
GAMBLING:
Yes No
q
Bingo
q
Slot Machines
q
Gaming Machine q
Card Table Games (Casino)
q
Informal/Illegal Types of Gambling
q
Horse Races
q
Sports Betting
q
Lottery Tickets
q
Instant Coin-Scratch
q
Internet Gambling
q
Gambling Stock Market/Real Estate
q
Betting on Games of Skill
q
Betting on Outcome of Events
q
None
q
Unknown
q
Other__________________________________
HEALTH:
***Leave Blank if unknown
o
Visually impaired
o
Hearing impaired
o
Mobility
qPhysically
challenged
o
Psychiatric Disorder
q
Blood Pressur
q
Cancer
q
Diabetes
q
Eating Disorder
q
HIV/AIDS
q
Heart Disease
q
Hepatitis A
q
Hepatitis B
q
Hepatitis C
q
Head Injury
q
Seizures/Epilepsy
q
Jaundice
q
Kidney Disease
q
Lice/Scabies
q
Liver
q
STD
q
Stomach Gastrointestinal
q
Tuberculosis
Is there any medical condition you feel we
should be aware of
q
Yes q
No (If yes please explain)
Medications you
are taking for any conditions
Methadone
q
Yes q
No
Name of medication Reason
for taking Dosage & Frequency Doctor’s Name
__________________ __________________
__________________ ___________________
__________________ __________________
__________________ ___________________
Number of
overnight hospitalizations in last 12 months for physical problems:
__________
Reason for most recent hospitalization:
_____________________________________________
_______________________________________________________________________________
1/
Diagnosed with a mental health problem by a qualified mental health
professional:
Within Last 12 months
q
Yes q
No Within Lifetime
q
Yes q
No
Most Recent Diagnosis
#1:_______________________________________________________________
Most Recent Diagnosis
#2:_______________________________________________________________
2/ Hospitalized for a mental health problem:
Within Last 12 months
q
Yes q
No Within Lifetime
q
Yes q
No
3/ Received treatment for a mental health, emotional,
behavioral or psychological problem from a community mental health program
or professional:
Currently
q
Yes q
No Within Last 12 Months
q
Yes q
No Within Lifetime
q
Yes q
No
Name of service
provider:______________________________________________________________
Contact Information
for service provider:__________________________________________________
4/ Prescribed medication for a mental health problem:
Currently
q
Yes q
No Within Last 12 Months
q
Yes q
No Within Lifetime
q
Yes q
No
TREATMENT HISTORY
Have you ever attended
an Alcohol / Drug Treatment program? ________ (If yes complete
following)
| Name of Centre |
Date Attended |
Length of Stay |
Completed?
YES/N0 |
(if no give reason |
Have you ever attended
outpatient counselling for your addiction? _____ (If yes complete the
following)
| Agency |
Date |
# Of Sessions |
# Of Sessions |
| |
|
|
|
| |
|
|
|
KEN BROWN RECOVERY HOME
PERSONAL GOALS &
OBJECTIVES
How do you feel the Ken
Brown Recovery Home can assist you in your recovery?
__________________________________________
Please describe
three (3) specific goals/objectives which you would like to accomplish
during your stay.
1.
_________________________________________________________________________________
____________________________________________________________________________________
2.
_________________________________________________________________________________
____________________________________________________________________________________
3.
_________________________________________________________________________________
_____________________________________________________________________________________
NOTE:
All residents are expected to participate fully in Recovery Home programs.
__________________________________
_______________________________
Signed
Date
Please forward
application to:
EXECUTIVE DIRECTOR
KEN BROWN RECOVERY HOME
8 Herrick Street
Sault Ste. Marie,
Ontario
P6A 2T4
FAX # (705) 942 3472
|