Sancta Maria House Admission Requirement Overview:

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Randell Oliver
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1 Sancta Maria House Admission Requirement Overview: Women 19 years of age or more. A Program for women who have a substance abuse/ addiction or another life changing addiction. You must be at least 5 days clean and sober, No Methadone clients accepted. For women coming from Detox it is advisable that they come straight to Sancta Maria House. TB test either skin test or X-Ray and Admission Medical Admission Forms to be completed and faxed to Sancta Maria prior to Intake Date. Must have prescription script or medications for at least one month. Women may request an interview at Sancta Maria House prior to admission if so desired. Women must be emotionally, physically and psychologically able to participate in all aspects of our program. Three month minimum commitment with open ended stay at Sancta Maria House. Sancta Maria House is a Stage One Healing and Recovery Home, women are not permitted free access to community unless escorted by staff. This is a Christian, 12 Step Program focused on spiritual, emotional, psychological and physical journey in healing, self discovery, Fees: $ per month, Income Assistance, Disability or Self Pay For Information call: Intakes: Monday to Friday 10-2 PM Potentially addictive medications such as opiates, benzodiazepines and barbiturates are not allowed. Women with paranoid thoughts and other fixed delusions, auditory, visual, or kinesthetic hallucinations, suicidal ideation or other thought disturbances which seem out of the person's control and not accessible to efforts to change indicate that Sancta Maria House would not be a suitable location to meet this persons particular needs.

2 Health Care card, SIN Card Passport, or photo ID and birth certificate Small amount of Toiletries and make up. Stamps, envelopes, pens and paper ( or Internet access in not provided). Weather-appropriate clothing and recreation wear (i.e.; rain wear, good sneakers). Sleepwear slippers, t-shirt, pajamas, housecoat, sweat pants. Some smart casual for outings and Church. 1 suitcase only Medications prescribed by physician. Please do not bring any of these items listed below to Sancta Maria House: Items with an asterick will be discarded upon admission. Alcohol.* Books/Magazines of any kind. Cameras. Candles. Cards and games. Cellular telephones or pagers. Cheque books and cheques. Cigars that are alcohol flavoured. Clothing that depicts alcohol, drugs, sex, violence and gambling paraphernalia or casinos. Clothing which is ripped, torn or very dirty. Computers/electronic devices. Drug paraphernalia.* Food or drinks brought in from outside Cedars.* Gambling paraphernalia.* Gum. Hair dye Hair spray (aerosol is okay). Keys. Knives. Light bulbs. Lottery or scratch tickets (will be mailed home to family). Matches. Medications (unless prescribed) and over-thecounter medications. Medication information printouts (unless given to you by our physician). Mood altering chemicals.* Nail polish and remover. Perfume, cologne, after-shave, strong perfumed lotions and bath products. Pictures/photo s that depict alcohol/drug usage, gambling, violence or sex. Purses. Sexually explicit clothing. Sheets Stuffed toys. Televisions, radios, stereos, clock radios, i- Pods, mp3 players, etc. Towels. Wallets. Weapons. Zippos, lighter fluid or butane ALSO, please be advised that any open packages of tobacco or cigarettes brought into treatment will be discarded. Note: All clothing will be searched upon admission.

3 SANCTA MARIA HOUSE PRE-ADMISSION INFORMATION Resident Name: Date / Time: Date of Birth: Phone: PHN: SIN Number: Address: Contact Person in case of Emergency: Address: Relationship: Phone: What is your drug of choice? When did you last use your drug of choice? When did you last use any other drugs or alcohol? What did you use? Do you need Detox? Yes No Are You in Detox at the Present Time: Yes No How many days did you use during the last month you were not in a facility? Have you ever been to a treatment center before? Yes No If Yes when, where and how long? Describe your usual withdrawal symptoms 1 1

4 PRE-ADMISSION INFORMATION: Do you or have you experienced seizures during withdrawal now or at any other time? Yes No Explain: Have you ever attempted suicide? Yes No When was the last incident? Do you have suicidal thoughts? Yes No how often? Have you been involved in prostitution? Yes No Length of time involved? Have you ever been assaulted by your partner? Yes No When was the last incident? Have you ever been charged or convicted of any crime (e.g. assault, breaking and entering, impaired driving, etc.)? Yes No If yes, when were you charged? Total time served? Please give details: Do you have charges pending or outstanding court cases? Yes No: If yes, please give Dates and Details: Dates Details of Court Case Lawyer s Name: Phone # Do you have supportive friends or family who do not use drugs? Friends Family Do you have any psychiatric or medical conditions that need to be treated? Yes If Yes: Please Speci 2 No 2

PRE-ADMISSION INFORMATION: Do you currently have a reliable source of income or financial support? Yes No If Yes what is it? Sancta Maria House Program Cost: $ 720.00 per month.

5 PRE-ADMISSION INFORMATION: Do you currently have a reliable source of income or financial support? Yes No If Yes what is it? Sancta Maria House Program Cost: $ per month. Income Assistance Disability Employment Insurance Self Pay Please Indicate Choice of Payment: Are you taking any prescription medication? Yes If yes please List: No Residents must have a Pre-Admission Medical, TB test within the last 6 months or a chest X-ray. Residents must have a severe addiction to drugs and/or alcohol which requires a residential facility. Residents must be female and at least 19 years of age or older. Residents must be drug and alcohol free for five days; this includes any prescription drugs that are considered mood altering i.e. Tylenol 3 s, Adivan, etc. All residents must be physically, psychologically and emotionally capable of taking part in all aspects of the program including one-to-one and group counseling. Residents must have no outstanding warrants or court dates that will conflict with their healing program. Residents must plan on completing a minimum of three months treatment upon intake. Residents must be open and willing to take part in the program and willing to explore their life, past issues, addiction, spirituality and recovery issues. There will be a 14 day stabilization period for residents of Sancta Maria in which they cannot leave the property unless previously arranged and accompanied by a staff, a screened volunteer, or a senior resident. 3 3

6 PRE-ADMISSION MEDICAL EVALUATION To be completed by a Physician Date: Phone No.: Client s Name: CLIENT INFORMATION RELEASE: To be signed by applicant I hereby permit Sancta Maria House to release medical information to my physician. Client s Signature Date PHYSICIANS PLEASE NOTE Clients can not participate in the Sancta Maria House program if they are under the influence of mood altering drugs. The above client is to be medically assessed as a potential participant in our residential healing program. Our program is designed to interrupt the destructive cycle of addiction to drugs and alcohol that has negatively affected the lives of our client population. Our clients must be physically, emotionally, and mentally capable of participating in a program of intense one-to-one and group counseling. To assist Sancta Maria House in assessing this client s suitability for treatment, please give detailed information to the following. Name of Physician: Telephone Number: 4 4

7 PRE-ADMISSION MEDICAL EVALUATION Fax Number: Mailing Address: Client Information: Height: cm Weight: kg Date of last Chest X-Ray and/or Mantoux Test and Results (if over one year, please refer for TB Test or Chest X-Ray): Allergies: Significant Current Medical Conditions: Psychiatric Conditions and History: History of Suicidal Ideation, Attempts, Slashing: Pyschosis: Current Medications: (Include OTC and PRN meds) Date Prescribed: Prescribed By: 5 5

8 PRE-ADMISSION MEDICAL EVALUATION Has there been any change in medication in the last 30 days? Please give details: If you are aware of any special problems, physical or psychological, that should be taken into account while the client is in Sancta Maria, please indicate and give details (i.e. extreme anxiety, suicidal tendencies, depression, etc.). Do you consider the client physically and psychologically fit/able to attend the Sancta Maria Program? Physician s Signature Date Please remind your patient Sancta Maria requires clients to be free from the affects of mood altering drugs, 6 6

9 PRE-ADMISSION MEDICAL EVALUATION including alcohol and prescription drugs) for a minimum of 5 days previous to intake. Withdrawal from these drugs should be done in the safest possible manner for your patient. Clients benefit most from our treatment program when a period of abstinence has been achieved. Please call Sancta (604) if you require further information. MEDICATION ALLOWED Anti-psychotics and Anti-depressants MEDICATION NOT ALLOWED Prescribed and "over the counter" (OTC) medications which Residents may NOT use when attending Sancta Maria House include Benzodiazepine type medications and all medication medications with codeine: Residents must have stopped taking these medications at least five days before coming to Sancta Maria House. Generic Name Aprazolam Bromazepan Chlordiazepoxide Clonazepam Clorazepate Diazepam Brand Name Xanax Librium Rivotril/Klonopin Tranxene Valium Generic Name Brand Name Estalzolam Prozom Flurazepam Dalmane Lorazepam Ativan Oxazepam Serax Temazepam Restoril Triazolam Halcion Opiates/Narcotics Methadone ASA with Codeine - 222, 223, 224 Tylenol (Acetaminophen) #1, #2 Any cough syrup with Codeine or Dextromethorpnan Prescribed: Generic Name Brand Name Tylenol #3, and #4 -acetaminophen/ codeine/ caffeine Percodan -aspirin / oxycodone Percocet -acetaminophen / oxycodone Diphenoxylate Lomotil Hydromorphone Dilaudid Meperidine Demerol Propoxypherie Darvon Fentanyl transdermal Duragesic Morphine sulfate Kadian Levophanol Levo-dramoran *Tramadol Ultram*relatively new *Tramacet 7 7

10 PRE-ADMISSION MEDICAL EVALUATION Other over the counter: (containing pseudoephedrine) Generic Name Dimehydrinate Diphenhydramine Sudafed Nytol Sleepeze Sominex Contact C Neo-Citrin Diphenoxylate Hydromorphone Meperidine Barbituates Fioricet Fioricet with codeine Fiorinal Fiorinal C (1/4, 1/2) Fiormal Brand Name Gravol Benadryl Lomotil Dilaudid Demerol acetamenophen/butalbitel/caffeine aspirin/butalbital aspirin/butalbital/codeine aspirin/butalbital/caffeine Secobarbital Tuinal Nembutal Phenobarbital Other Sedatives Chloral Hydrate Meprobamate Benzodiazepine - like ("Z" - drugs) Imovane Rhovane Ambien 0r Ambien CR Eszopiclone Starnoc Seconal, Miltown Zoplicone Zolpidem Lunesta Revised

11 Revised

APPLICATION FORM NAME:

APPLICATION FORM NAME: Application Date: Birthdate: SIN#: Requested Date for Residency: Present Address: Phone #: How long at this address? MSP #: Marital Status: Employment Status: Education: Emergency