BASIC INFORMATION. Street Address (including city) Phone Number Can we leave messages? YES

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1 Note to Applicants Please complete all aspects of the Addictions Services Application Package. Applications that are incomplete cannot be processed. Please note that if you wish to attend the Anchorage program, you will first enter residential programming through the Stabilization program. BASIC INFORMATION First Name Middle Name Last Name Date of Birth (Month/Day/Year) Source of Income Marital Status Street Address (including city) Phone Number Can we leave messages? YES or NO Do you identify as a member of a visible minority? Do you identify as a person of Aboriginal descent? What is your primary language? Please identify other languages you are able to communicate in: If English is not your primary language, are you able to receive services in English? How did you hear about the Stabilization Program? (Please check off) Ottawa Withdrawal Management Centre Ottawa Withdrawal Management Centre Partnership Correctional facility/legal System Community (friend, family member) Other (please state): Emergency Contact Name Phone Number Relationship PHYSICAL HEALTH Family Doctor s Name Address of Clinic Date of Last Visit Reason for last visit? How many times have you been hospitalized in the past year? Please describe the reasons for any hospitalizations in the past year Do you have any allergies to foods or medication? yes, to what? If

2 Do you have any dietary restrictions? yes, please describe Do you have any serious medical conditions or issues with mobility? If yes, please describe: Are you able to sleep on a top bunk? If Do you have a history of seizures? yes, please describe: If Are you currently taking any medications? If you are taking any (prescription or over-the-counter) medications, please complete the following table: Medication Dose Reason How long have you been taking it? Are you taking it as prescribed?

3 Please note that clients can be accepted into Stabilization while on various types of medications. However, we do not support the use of benzodiazepines and/or narcotics in long-term treatment. Clients currently prescribed benzodiazepines and/or narcotics will be asked to reduce and taper off their dosages under medical supervision from a doctor. *In medically EXCEPTIONAL circumstances, the Addiction Services clinical team may consider allowing benzodiazepines/narcotics for clients presenting with severe physical or mental health issues on an individual basis who have limited treatment options available to them and/or if switching their medications would cause significant life impairment/harm. Clients in these circumstances will be asked to provide medical documentation to support their application in these cases. Additionally, clients may choose to have their prescriptions transferred to Respect Rx pharmacy, who may deliver medications on site on a weekly basis. Please note that any changes to medication(s) MUST be discussed with your primary counsellor. Are you in agreement to the above specifications? Do you currently use any opiate replacement therapies (ie. Methadone, suboxone)?* We welcome clients who are on opiate replacement therapies. Clients who are new to program may be referred to a doctor if they wish. Clients who are well established with their opiate replacement therapy practitioners may choose to continue with service providers off-site while they are in our programs. *Please be aware that clients are NOT permitted to store methadone anywhere on site. Clients must have their methadone dispensed daily from a clinic or pharmacy. Suboxone is accepted on site and is taken in front of a staff member. Additionally, clients are not permitted to start opiate replacement therapies once in Anchorage. Are you in agreement to the policies surrounding the use of opiate replacement therapies? *Please note if you answer no to abiding by our opiate replacement therapy policies, we will not be able to accept you into the program MENTAL HEALTH Please know that a history of mental health issues does not exclude you from accessing services. In order to best meet the needs of clients in our programs, we request information regarding your mental health history. Have you ever been diagnosed with a mental health disorder (including but not limited to anxiety, depression, ADHD, schizophrenia, etc.? If yes, please describe:

4 Have you ever received treatment related to a mental health concern before? If yes, please state where and when: Do you believe that you require mental health support? yes, please describe: If Have you ever had thoughts of suicide? Have you ever attempted suicide? If yes, please state the number of times and date of most recent attempt: Do you currently have thoughts of suicide? EMPLOYMENT Please note that while in Stabilization at The Salvation Army Ottawa Booth Centre, clients are not permitted to work for the purpose of generating income. Clients in Anchorage are not permitted to work until they are in the final 4 weeks of their program in order to support transitional plans (to a maximum of hours per week). Will you be able to commit to not working while in Stabilization (and Anchorage)? What was your previous area of work? : EDUCATION It is our mission to do our best to serve everyone, regardless of educational abilities or needs. Groups as part of Addictions Services at The Salvation Army Ottawa Booth Centre are taught using many different styles of instruction and require the ability to read and complete written work. We would like to know about any additional support you may need in order to be able to fully participate in our programs. Do you require any assistance in being able to read or complete written work? yes, what do you require? If What is the highest level of education you have completed? Have you ever been diagnosed with a learning or developmental disability? yes, please describe: If *Please note that no matter what level of literacy or ability, this will not impact your acceptance to service. We will accept all levels of client literacy and learning ability. LEGAL ISSUES AND HISTORY

5 Please note that a history of violent offences does not necessarily exclude you from participating in programming. However, we do want to gather some information in order to best serve you. Staff may also request information pertaining to criminal charges if necessary. Are you currently involved in the legal system? Do you have charges pending? yes, please state your pending charges: If Are you (or will you be) on probation or parole? Do you have a Probation or Parole Officer? yes, please provide their name and contact information: If Do you have a lawyer? If yes, please provide their name and contact information: Is it mandatory for you to be in a treatment program? Have you ever been convicted of a violent offence? yes, please state the nature of the offence(s): If SUBSTANCE USE HISTORY Please state your substance(s) of choice and describe their use below: Substance of Choice How much do you normally use at one time? How often do you use this substance? How do you use this substance? (smoke, inject, etc) How long has this substance use been a problem from you? Date of Last Use Please note that the Stabilization program requires 4 hours of sobriety prior to intake. For Ottawa Withdrawal Management Pathway clients, you will be expected to maintain sobriety between your discharge from OWMC and intake to Stabilization. For clients who use marijuana, there is an expectation that urine screens will be negative

6 for THC six (6) weeks following their intake date. Clients may be discharged from program if urine screens after 6 weeks are not negative for THC. Do you identify as having a co-occurring addiction (gambling, sex, shopping, etc.)? yes, please describe: If TREATMENT HISTORY AND GOALS Have you ever been to a treatment program for substance use in the past? yes, please complete the following table: Name of Agency Dates Length of Program Did you complete the program? If If you did not complete the program, what was the reason? The Stabilization Program is available to support you for up to 9 days while you work towards your goals in recovery. While in Stabilization, many clients pursue long-term treatment or safe housing. Please describe where you plan on going after Stabilization (i.e. Anchorage, other treatment programs, safe housing, etc.): SPIRITUALITY The Salvation Army Ottawa Booth Centre is a social services ministry unit of The Salvation Army church. We provide effective, client-centered, programs and services, which respond to physical, emotional, and spiritual needs and is given with respect and dignity for all. Since there is proven value in spiritual care for well-being and connection, Addictions Services include for clients in the program: Daily chapel services to motivate and inspire Spirituality class to explore personal beliefs and values and to discover how faiths and spirituality can be transformational and empowering. Various faiths and customs are explored. Opportunity for individual pastoral counseling sessions for added support and spiritual resources COMMUNAL LIVING Please be aware that the Stabilization program is located in an emergency shelter setting. The program is located on the 4 th floor of the building and the bedrooms are shared by two to four residents each. Are you comfortable living in a communal living setting?

7 Have you ever had any problems with communal living? If yes, please describe: In signing below, I acknowledge that all of the information in this application is true to the best of my knowledge. Applicant Signature Date BECK DEPRESSION INVENTORY (BDI, -items) Name: Date: On this questionnaire are groups of statements. Please read each group of statements carefully. Then pick out the one statement in each group which best describes the way you have been feeling the past week, including today. Circle the number to the right of the statement you picked. If several statements in the group seem to apply equally well, circle each one. Be sure to read all statements in each group before making your choice.. I do not feel sad I feel sad I am sad all the time and can't snap out of it I am so sad or unhappy that I can't stand it. I am not particularly discouraged about the future I feel discouraged about the future I feel I have nothing to look forward to I feel that the future is hopeless and that things cannot improve. I do not feel like a failure I feel I have failed more than the average person As I look back on my life, all I can see is a lot of failure I feel I am a complete failure as a person 4. I get as much satisfaction out of things as I used to I don't enjoy things the way I used to I don't get real satisfaction out of anything anymore I am dissatisfied or bored with everything 5. I don't feel particularly guilty I feel guilty a good part of the time I feel quite guilty most of the time I feel guilty all of the time

8 6. I don't feel I am being punished I feel I might be punished I expect to be punished I feel I am being punished 7. I don't feel disappointed in myself I am disappointed in myself I am disgusted with myself I hate myself 8. I don't feel I am any worse than anybody else I am critical of myself for my weaknesses or mistakes I blame myself all the time for my faults I blame myself for everything bad that happens 9. I don't have any thoughts of killing myself I have thoughts of killing myself, but I would not carry them out I would like to kill myself I would kill myself if I had the chance. I don't cry any more than usual I cry more now than I used to I cry all the time now I used to be able to cry, but now I can't cry even though I want to. I am no more irritated now than I ever am I get annoyed or irritated more easily than I used to I feel irritated all the time now I don't get irritated at all by the things that used to irritate me. I have not lost interest in other people I am less interested in other people than I used to be I have lost most of my interest in other people I have lost all of my interest in other people. I make decisions about as well as I ever could I put off making decisions more than I used to I have greater difficulty in making decisions than before I can't make decisions at all anymore

9 4. I don't feel I look any worse than I used to I am worried that I am looking old or unattractive I feel that there are permanent chances in my appearance that make me look unattractive I believe that I look ugly 5. I can work about as well as before It takes extra effort to get started at doing something I have to push myself very hard to do anything I can't do any work at all 6. I can sleep as well as usual I don't sleep as well as I used to I wake up - hours earlier than usual and find it hard to get back to sleep I wake up several hours earlier than I used to and cannot get back to sleep 7. I don't get more tired than usual I get tired more easily than I used to I get tired from doing almost anything I get too tired to do anything 8. My appetite is no worse than usual My appetite is not as good as it used to be My appetite is much worse now I have no appetite at all anymore 9. I haven't lost much weight, if any, lately I have lost more than 5 pounds I have lost more than pounds I have lost more than 5 pounds I am purposely trying to lose weight by eating less Yes No. I am no more worried about my health than usual I am worried about physical problems such as aches and pain; or upset stomach; or constipation I am very worried about physical problems and it's hard to think of much else I am so worried about my physical problems that I cannot think about anything else

10 . I have not noticed any recent chance in my interest in sex I am less interested in sex than I used to be I am much less interested in sex now I have lost interest in sex completely Beck, Ward, & Mendelson, 96 Screening criterion: score of or higher. Primary Care Evaluation of Mental Disorders: PRIME MD - depression questions ( questions) Question Yes or No. During the past month, have you often been bothered by feeling down, depressed, or hopeless?. During the past month, have you often been bothered by little interest or pleasure in doing things?

11 THE DRUG ABUSE SCREENING TEST (DAST) Directions: The following questions concern information about your involvement with drugs. Drug abuse refers to () the use of prescribed or over-the-counter drugs in excess of the directions, and () any non-medical use of drugs. Consider the past year ( months) and carefully read each statement. Then decide whether your answer is and circle the appropriate space. Please be sure to answer every question.. Have you used drugs other than those required for medical reasons? YES NO. Have you abused prescription drugs? YES NO. Do you abuse more than one drug at a time? YES NO 4. Can you get through the week without using drugs (other than those required for medical reasons)? YES NO 5. Are you always able to stop using drugs when you want to? YES NO 6. Do you abuse drugs on a continuous basis? YES NO 7. Do you try to limit your drug use to certain situations? YES NO 8. Have you had blackouts or flashbacks as a result of drug use? YES NO 9. Do you ever feel bad about your drug abuse? YES NO. Does your spouse (or parents) ever complain about your involvement with drugs? YES NO. Do your friends or relatives know or suspect you abuse drugs? YES NO. Has drug abuse ever created problems between you and your spouse?. Has any family member ever sought help for problems related to your drug use? YES NO YES NO 4. Have you ever lost friends because of your use of drugs? YES NO 5. Have you ever neglected your family or missed work because of your use of drugs? YES NO 6. Have you ever been in trouble at work because of drug abuse? YES NO THE MICHIGAN ALCOHOLISM SCREENING TEST (MAST)

12 . Do you feel you are a normal drinker? ("normal" is defined as drinking as much or less than most other people). Have you ever awakened the morning after drinking the night before and found that you could not remember a part of the evening?. Does any near relative or close friend ever worry or complain about your drinking? 4. Can you stop drinking without difficulty after one or two drinks? 5. Do you ever feel guilty about your drinking? 6. Have you ever attended a meeting of Alcoholics Anonymous (AA)? 7. Have you ever gotten into physical fights when drinking? 8. Has drinking ever created problems between you and a near relative or close friend? 9. Has any family member or close friend gone to anyone for help about your drinking?. Have you ever lost friends because of your drinking?. Have you ever gotten into trouble at work because of drinking?. Have you ever lost a job because of drinking?. Have you ever neglected your obligations, family, or work for two or more days in a row because you were drinking? 4. Do you drink before noon fairly often? 5. Have you ever been told you have liver trouble, such as cirrhosis? 6. After heavy drinking, have you ever had delirium tremens (DTs), severe shaking, visual or auditory (hearing) hallucinations? 7. Have you ever gone to anyone for help about your drinking? 8. Have you ever been hospitalized because of drinking?

13 9. Has your drinking ever resulted in your being hospitalized in a psychiatric ward?. Have you ever gone to any doctor, social worker, clergyman, or mental health clinic for help with any emotional problem in which drinking was part of the problem?. Have you been arrested more than once for driving under the influence of alcohol?. Have you ever been arrested, or detained by an official for a few hours, because of other behavior while drinking? Scoring the MAST Test Score one point if you answered "no" to the following questions: or 4. Score one point if you answered "yes" to the following questions:,, 5 through. A total score of six or more indicates hazardous drinking or alcohol dependence and further evaluation by a healthcare professional is recommended.

14 UNIVERSITY OF RHODE ISLAND CHANGE ASSESSMENT SCALE (URICA) Each statement below describes how a person might feel when starting therapy or approaching problems in his life. Please indicate the extent to which you tend to agree or disagree with each statement. In each case, make your choice in terms of how you feel right now, not what you have felt in the past or would like to feel. For all the statements that refer to your "problem," answer in terms of problems related to your drinking (illegal drug use). The words "here" and "this place" refer to your treatment center. There are five possible responses to each of the items in the questionnaire: = Strongly Disagree = Disagree = Undecided 4 = Agree 5 = Strongly Agree Circle the number that best describes how much you agree or disagree with each statement. STRONGLY STRONGLY DISAGREE UNDECIDED AGREE DISAGREE AGREE. As far as I'm concerned, I don't have any problems 4 5 that need changing.. I think I might be ready for 4 5 some self-improvement.. I am doing something about the problems that 4 5 had been bothering me. 4. It might be worthwhile to 4 5 work on my problem. 5. I'm not the problem one. It doesn't make much sense 4 5 for me to consider changing. 6. It worries me that I might slip back on a problem I 4 5 have already changed, so I am looking for help. 7. I am finally doing some

15 4 5 work on my problem. 8. I've been thinking that I might want to change 4 5 something about myself.

16 9. I have been successful in working on my problem, 4 5 but I'm not sure I can keep up the effort on my own.. At times my problem is difficult, but I'm working on 4 5 it.. Trying to change is pretty much a waste of time for 5 me because the problem 4 doesn't have to do with me.. I'm hoping that I will be able to understand myself 4 5 better.. I guess I have faults, but there's nothing that I really 4 5 need to change. 4. I am really working hard to 4 5 change. 5. I have a problem, and I really think I should work 4 5 on it. 6. I'm not following through with what I had already changed as well as I had 4 5 hoped, and I want to prevent a relapse of the problem. 7. Even though I'm not always successful in 4 5 changing, I am at least working on my problem. 8. I thought once I had resolved the problem I would be free of it, but 4 5 sometimes I still find myself struggling with it. 9. I wish I had more ideas on 4 5 how to solve my problem.. I have started working on my problem, but I would 4 5 like help.. Maybe someone or something will be able to help me.. I may need a boost right 4 5

17 now to help me maintain the changes I've already made.. I may be part of the problem, but I don't really think I am. 4. I hope that someone will have some good advice for me. 5. Anyone can talk about changing; I'm actually doing something about it. 6. All this talk about psychology is boring. Why can't people just forget about their problems? 7. I'm struggling to prevent myself from having a relapse of my problem. 8. It is frustrating, but I feel I might be having a recurrence of a problem I thought I had resolved. 9. I have worries, but so does the next guy. Why spend time thinking about them?. I am actively working on my problem.. I would rather cope with my faults than try to change them. Scoring Precontemplation items, 5,,,, 6, 9, Contemplation items, 4, 8,, 5, 9,, 4 Action items, 7,, 4, 7,, 5, Maintenance items 6, 9, 6, 8,, 7, 8,

18 COPYRIGHT McLean Hospital Department of Mental Health Services Evaluation (B.8 GAIN-Short Screener (GAIN-SS) Version [GVER]: GAIN-SS.. What is your name? a. b. c. (First name) (M.I.) (Last name) What is today s date? (MM/DD/YYYY) / / The following questions are about common psychological, behavioral, and personal problems. These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can t go on. After each of the following questions, please tell us the last time that you had the problem, if ever, by answering, In the past month (), - months ago (), or more years ago (), or Never ().. When was the last time that you had significant problems a. With feeling very trapped, lonely, sad, blue, depressed, or hopeless about the future?.. b. With sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?. c. With feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen? d. With becoming very distressed and update when something reminded you of the past?. e. With thinking about ending your life or committing suicide?.. When was the last time that you did the following things two or more times? f. Lied or conned to get things you wanted or to avoid having to do something?. g. Had a hard time paying attention at school, work, or home?. h. Had a hard time listening to instructions at school, work, or home?.. i. Were a bully or threatened other people? j. Started physical fights with other people?... When was the last time that k. You used alcohol or other drugs weekly or more often?..... l. You spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or feeling the effects of alcohol or other drugs?.. m. You kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people? n. Your use of alcohol or other drugs caused you to give up, reduce or have problems at important activities at work, school, home, or social events?..

19 o. You had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or that you used any alcohol or other drugs to stop being sick or avoid withdrawal problems? 4. When was the last time that you p. Had a disagreement in which you pushed, grabbed, or shoved someone?.. q. Took something from a store without paying for it?.. r. Sold, distributed, or helped to make illegal drugs?.. s. Drove a vehicle while under the influence of alcohol or illegal drugs?. t. Purposely damaged or destroyed property that did not belong to you? Do you have other significant psychological, behavioural, or personal problems that you want treatment for or help with? (If yes, please describe below) u. v. w. 6. What is your gender? (If other, please describe below) -Male -Female 99-Other x. 7. How old are you today? years FOR STAFF USE ONLY 8. Site ID: Site Name v. 9. Staff ID: Staff Name v.. Client ID: Comment v.. Mode: ) Administered by staff ) Administered by other ) Self-administered. Number of s and s: IDSscr: EDScr: SDScr: CVScr: TDScr:. Referral: MH: SA: ANG: Other: b Referral Code: 4. Referral comments: Copyright 5-8 Chestnut Health Systems GAIN-SS...doc 7//8