NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE

New Port Centre NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne ON, L3K 2N7 Phone (905) 378-4647 Ext 32500 Fax: (905) 834-3002 E-mail: NewPortAdmin@niagarahealth.on.ca A D M I S S I O N S I N F O R M A T I O N General Admission Information Referrals to our residential services are accepted from drug and alcohol treatment providers. New Port Centre does not accept self-referrals. For information on drug and alcohol treatment providers in your area, contact the Ontario Drug and Alcohol Registry of Treatment (DART) by phone at 1-800-565-8603 or visit their website (www.dart.on.ca). Referrals to New Port Centre can be made by fax. To make a referral to our residential services, have your treatment provider complete and forward a New Port Centre Intake Package to our Intake Department. The Intake Package can be downloaded from our website: www.niagarahealth.on.ca/en/mental -health-addictions#addictions A complete referral includes the following: New Port Centre Intake package forms 1. New Port Centre Intake Form (1 page) 2. New Port Centre Medical Profile (2 pages) to be completed by a physician 3. Legal History Questionnaire 4. n-smoking Agreement 5. Photocopy of a VALID Health Card Completed Provincial Assessment Tools 6. DHQ Drug History Questionnaire 7. Adverse Consequences Questionnaire 8. Tracking Sheet With Scores of Other Assessments Please call Roberta, Intake Coordinator, at 905-378-4647, Extension 32524 if you have any questions regarding your referral to New Port. REFERRALS WILL BE PROCESSED WITHIN SEVEN (7) WORKING DAYS FROM RECEIPT. The client will be notified after review of file. The Medical Profile Form must be completed by a physician and list all prescription and non-prescription medication (including vitamins) that the client plans to take during their residential treatment stay. When coming to New Port for residential treatment, clients should bring their valid Ontario Health Card and proof of drug benefit eligibility. We expect people attending residential treatment to be neither under the influence of non-prescribed drugs or alcohol, nor experiencing any withdrawal symptoms. If a person is assessed as being medically unstable, they will be directed to NHS withdrawal management services for assessment before admission. If a person is assessed as being under the influence of a mood-altering substance and attempts to operate a motor vehicle, we are obligated to notify the police. Revised: 05/04/13

Page 2 of 2 A D M I S S I O N S I N F O R M A T I O N Information For People On Methadone On admission day, please have your daily methadone drink before you arrive. Your prescription should be dated to begin the day after admission and to end on the last day of treatment. Methadone script must be faxed to Boggio Pharmacy prior to admission date. Information For Prescribing Physicians If your patient is being referred to New Port Centre residential services, please complete a Medical Profile Form for them. The Medical Profile Form must detail all prescription and non-prescription medication (including vitamins) that your patient plans to take while in residential treatment. When New Port Centre has confirmed a residential admission date for your patient, please fax an 18-day prescription for all medications to Boggio Pharmacy prior to that date. Also, please arrange for Boggio Pharmacy to receive an original copy of ANY prescriptions containing narcotics (your patient can bring this copy with them on admission day). Boggio Pharmacy will blister pack the medication and charge a dispensing fee at applicable rates. Boggio Pharmacy Phone: 905-834-3514 200 Catharine Street Fax: 905-834-6252 Port Colborne, ON L3K 4K8 Alternately, please have your patient s pharmacy blister pack 18 days worth of prescription medication for their residential stay. Vitamins and other non-prescription medication should be blister packed and authorized by the doctor who completes the Medical Profile Form. Information For Correctional Services Referrals New Port Centre and the Ontario Ministry of Community Safety and Correctional Services and Correctional Service of Canada co-operate to offer treatment for substance use to people involved in the correctional system. New Port Centre does not accept self-referrals. Correctional services should complete and forward a New Port Centre Intake Package with Provincial standardized assessment information to our Intake Department. In addition, signed consent to share information between New Port Centre and Correctional Services is required. When such consent is received, New Port Centre will contact Correctional Services to collect information in order to appropriately assess the person s suitability for our residential treatment program. This information includes background charges, conduct and attendance at programming during incarceration and any concerns regarding violence, anger, non-compliance or lethality. Revised: 05/04/13

Date Last Revised April 5, 2013 Client First Name: Client Last Name: New Port Centre Fax# (905) 834-3002 Referral Date / / ( D D / M M / YY) Niag ar a Health S ys tem Port Colborn e Ge ne ral Site 260 Suga rloaf Street, Port Colbor ne, ON, L3K 2N7 Phone: (9 05) 37 8-464 7 E xt. 3250 0 Fax: (9 05 ) 83 4-3 002 NPC Client # Em ail: NewP ortadm in@ni a gar ah ealth. on.ca W eb: www. niaga ra hea lth.on.ca/en/mental -he alth -a ddi c tions#ad dictions I N T A K E F O R M Date of Birth: (DD MM - YY) Gender: Male / Female 1. Last Name at Birth: 2. Home Phone: ( ) 3. Address: Apt 4. City, Province: 5. Postal Code: I.D. Agency When Calling: / If : Referral Agency: Referral Agent Name: Referral Phone: ( ) Health Card #: Ethnicity: Ver: In Patient Program: Out Patient Program: Current Problem Substances # Days Used in Last Month Substances Used in Last Year (check all that apply) ne Alcohol Amphetamines Barbiturates Benzodiazepines Cannabis Cocaine Crack Crystal Meth Ecstasy Glue / Inhalants Hallucinogens Heroin / Opium OTHER Psychoactives OTC Codeine Prescription Opioids Steroids Tobacco Next of Kin: Relation: n medical Injection Drug Use (Circle 1) Next of Kin Phone: ( ) 1. Never Injected Ever Married: / 2. Injected prior to 1 year ago Current Marital Status: 3. Injected in last year Highest Education: Employment: Full Part Looking t looking Source of Income: Physical Health Legal Issues: Y/N Type: Young Offender: / Mandated Admission: / If yes: CAS / Court / Work / Family Family Doctor: Dr. Phone: ( ) Psychiatrist: Psych Dr. Phone: ( ) Taking Methadone Visual Impairment Hearing Impairment Mobility/Physical Impairment Pregnant Gambling Problem # of overnight hospitalizations last year Mental Health History Diagnosed w Diagnosed in Lifetime Hospitalized Last year Hospitalized in Lifetime Counselling/Support/Tx w Counselling/Support/Tx in Last Year Counselling/Support/Tx Ever Prescribed Medication w Prescribed Medication in Last Year Prescribed Medication - Ever Mental Health Diagnosis & Prescribed Meds: A New Port Centre Medical Profile Form must be received before an In Patient bed date is assigned

New Port Centre NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne, ON L3K 2N7 Phone (905) 378-4647 Ext 32500 Fax: (905) 834-3002 E-mail: NewPortAdmin@niagarahealth.on.ca Web: www.niagarahealth.on.ca/en/mental-health-addictions#addictions Dear Doctor/Nurse Practitioner: Your patient has applied for admission to the residential component of treatment for treatment of his/her addiction(s) at the New Port Centre. The New Port Centre is a non-medical, non-psychiatric treatment centre for substance abuse. As a non-medical, non-psychiatric facility, we require the thorough and accurate completion of the enclosed Medical Profile to ensure that it is consistent with the medications that the client has been prescribed. For example, if a patient is taking an antidepressant, we would consider that the patient suffers from depression and that would be considered a psychiatric disorder. The list of current medications must be legible and complete on the Medical Profile form provided i.e. correct medication, correct dose, correct time and the correct route that the medication should be given. New Port addiction counsellors are non-medical personnel and it is essential that all information be complete. We have no access to psychiatric consultation other than the local emergency department; therefore we ask that clients be deemed stable with any psychiatric condition that they may have been diagnosed with, before attending New Port Centre. Inaccurate, incomplete, non-legible medical profiles will delay the intake process for your patient. Many thanks for your attention to these vital safety issues. Sincerely, Management, New Port Centre Revised: 05/04/13

Affix patient label here New Port Centre Niagara Health System, Port Colborne Site, 260 Sugarloaf St. Port Colborne ON Phone: 905-834-4501 Ext. 32500 Fax 905 834 3002 Medical History: Please have this form completed by your health care provider Name: DOB: 1) Substance(s) use: Please briefly outline the substance(s) and pattern of use that has prompted this referral 2) Allergies: Known Allergies If yes please specify: Allergan Response 3) Diet: Does your client/patient require a special diet? If so please specify: 4) Immunization History: (te: Immunizations are not mandatory for admission) Which of the following immunizations has your client/patient received? Tetanus Year Unknown Comments Hepatitis A Series Year Unknown Hepatitis B Series Year Unknown 5) Screening History : (te: Screening is not mandatory for admission) Hepatitis B Year Unknown Comments/Results Hepatitis C Year Unknown HIV Year Unknown 6) Smoking: New Port is a non smoking program. (Clients are required to bring an eighteen day supply of a smoking cessation aid if required) n Smoker Smoker Number/Day? 1

7) Mental Health: Does the client/patient have a history of mental health diagnoses? Unknown If yes please specify: New Port has an affiliated psychiatrist available for consult. Please indicate if you would like your client/patient to have an appointment with the psychiatrist. If yes then please briefly outline the relevant history and the objectives of the consult. A copy of the consult will be sent to the ordering provider. Provider Name Billing Number 8) Medications: Please List all medications that your client is currently prescribed Medication Dose Frequency 9) Health: Please list any medical information including acute or chronic disorders, physical limitations etc. Provider Signature Office Stamp Print Name Client/Patient Signature Date: 2

Affix Patient Label New Port Centre NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne, ON L3K 2N7 Phone (905) 378-4647 Ext 32500 Fax: (905) 834-3002 E-mail: NewPortAdmin@niagarahealth.on.ca Web: www.niagarahealth.on.ca/en/mental-health-addictions#addictions NON-SMOKING POLICY AGREEMENT 1, am aware that the New Port Centre is an (Print Name) abstinence based substance abuse treatment facility including nicotine and as a client I agree to the following: a) To respect the non-smoking policies of the New Port Centre/Niagara Health System b) To arrive for my admission date a minimum of 5 days tobacco free c) To arrive for my admission with enough Nicotine Replacement Therapy aids for my stay in residential treatment (i.e. nicotine patches, gum, lozenges or inhalers). I am aware that the decision to smoke in the building or on the property of the Niagara Health System will jeopardize my ability to remain in the program and may result in discharge from the program. I am aware that to assist me in being tobacco free the New Port Centre will offer access to acupuncture, impact of smoke inhalants education sessions, individual counselling and relaxation therapy techniques. Signature: Witness: Date: (DD/MM/YY) Revised Date: JAN/14