Intake Form

Section One: Admissions and Discharge Criteria

Criteria for the admission of the clientele to the Biidaaban Healing Lodge will be as follows:

1. All relevant forms contained within the referral package must be completed by the appropriate individual and returned to the Biidaaban Healing Lodge by the assigned date. The assigned date will be determined by the counselling unit. The following forms will make up the referral package: Residential Treatment Referral Package, Client Medical Information Form, Oath of Confidentiality and Things to Bring.

2. Individuals wishing to access any of the programs offered through the Biidaaban Healing Lodge must participate willingly and be free from ALL court involvement during the treatment process.

3. All clients must sign Oaths binding them to confidentiality while attending programs at the Biidaaban Healing Lodge. They must also ensure that confidentiality is an ongoing commitment once they leave the healing program.

4. Upon arrival, clients must be willing to participate in an assessment with the assigned counselor in order to develop a treatment plan specifying goals and objectives to be worked on during their treatment process.

5. Clients must be willing to participate in an overall introduction to the Biidaaban Healing Lodge and abide by the rules of conduct when in the care of the facility. Please review Client Rules and Expectations document.

Criteria for completion of the program by clientele from the Biidaaban Healing Lodge are as follows:

1. The client has successfully completed all components of the identified program.

2. The counseling staff is satisfied with the progress and level of commitment of the client in the specified program.

3. Successful completion of all goals and objectives outlined by the lodge staff in the initial plans of care.

4. A detailed discharge summary and treatment plan has been developed prior to the commencement of treatment at the healing lodge.

5. That the client has been made aware of the supportive programs and services within their community of origin that may enrich recovery and wellness

6. That adequate arrangements have been made to transport the client to their home community once treatment has been completed.

Criteria for discharge of the clientele from the Biidaaban Healing Lodge are as follows:

1. At any point during the treatment process where it is assessed that a client is not participating honestly in any component of the program, if they have demonstrated violent behavior toward a staff member or client, if they are disrupting the treatment process of their peers or where it has been assessed that continuing treatment is a risk to their health, Biidaaban Healing Lodge reserves the right to discharge the client from our program.

2. In the event that a client’s current patterns of substance use interfere with their treatment process, Biidaaban Healing Lodge reserves the right to discharge clients who have not been forth coming with regards to their current patterns of substance use

3. Not participating in the graduation and the discharge ceremonies.

Section Two: General Information

*Please indicate what treatment program you are applying for:

Five-day Anger Solutions

Ten-day Sexual Abuse Survivors

Ten-day Grief and Abandonment

Five-day Children of Trauma

*Have you attended programs at Biidaaban Healing Lodge before?

Yes

*Client Name

*Primary Email

*Complete Mailing Address

*Phone Number

*Status Number

*Health Card Number

Spouse's Name:

Spouse's Mailing Address:

Name of child

Date of Birth

Do they reside with you

Yes

Name of child

Date of Birth

Do they reside with you

Yes

Please list any significant information with respect to your child(ren) – long-term illness, childhood trauma, death of child etc

Has a child welfare or protection agency ever been involved with your family?

Yes

Please summarize this involvement

Section 3: Medical Information

Physician’s Name

Physician’s Phone Number

How long have you been under the care of this physician?

Please List Medical Conditions

Prescribed Medication & Dosage

Please explain any special medical needs and/or conditions that you have. (allergies, dietary needs, mobility issues etc)

Have you ever been diagnosed with a mental illness?

Yes

If yes, please explain your history with respect to this

Have you ever contracted any communicable diseases or illnesses? Tuberculosis, HIV, Hepatitis C, Bed bugs, Lice etc

Yes

When?

How was it dealt with?

Is it an issue now?

Please have your family doctor/practitioner fill out the Medical Form attached to this referral package.

Intake Form

Section One: Admissions and Discharge Criteria

Section Two: General Information

Section 3: Medical Information

Section Four: Addiction History

Section Five: Family of Origin

Section Six: Information About You

Section Seven: The Law