‘Namgis Treatment Centre
Application Package
The Client Application package is to be completed by the Referral worker and the
Client together. Client self- referrals are not accepted
Application Package includes:
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Memo to: NNADAP Assessment and Referral Workers – page 3
Referral Worker Checklist – pages 4 & 5
Application Package – pages 6 - 12
Consent Form – page 13
Preadmission Medical Evaluation Form – page 14
Preadmission Medical Examination – pages 15 & 16
939 TB Screen Test Form – page 17
Suicide Risk Assessment Form – pages 18 & 19
‘Namgis Pre-treatment Agreements – pages 21 - 25
Client’s Checklist – page 26
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Namgis Treatment Centre
‘Namgis Treatment Centre
Application Package
_______________________________________________
Mary Hunt, Intake Coordinator
P.O. Box 290
Alert Bay, BC V0N 1A0
Phone: 250-974-5522 Ext. 2131
Intake Fax #: 250-974-2257 or Alternate Fax: 250-974-2736
Email: MaryH@namgis.bc.ca
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Namgis Treatment Centre
‘Namgis
Substance Abuse
Treatment Centre Society
P.O. Box 290,
Alert Bay B.C., V0N 1A0
Ph: (250) 974-5522
Fax: (250) 974-2257
To: NNADAP Assessment and Referral Workers
As we understand the struggle of addiction, so is the struggle for change and recovery.
Through intake outcome evaluation, the ‘Namgis Treatment Centre (NTC) have
identified a few areas of the referral and intake process that need to be addressed.
We are sending out an updated Referral Package and ask that you review the criteria
for intake with your client. Often we receive referrals that are missing important
information and look to improve the quality of service with the intake process.
Here are a few items that have cause to be addressed:
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Clean Time: We require a minimal ten (10) days substance free and to be clear
of medical detoxification.
Medications: All prescriptions up to date and in a blister pack if needed.
Prescribed narcotics will not be dispensed during the six week program.
Probation: Clients on probation are required to submit a copy of their probation
order prior to entering the program.
Court issues: Court dates are not to fall during intake dates. Referrals will be
screened by a review panel and decision made pending the nature of the
offence. We do not accept sex offenders.
Travel: Travel costs are the responsibility of the referral worker to arrange with
the client. We ask that that you have pre arrangements for return travel in case
the client decides to leave the program before completion or is discharged early
for inappropriate group behavior.
Preparedness and Readiness: Residents will be orientated to house chores and
guidelines in the first week of the program. In order to focus on their work,
residents are to insure business matters are taken care of prior to arriving.
The Staff of the ‘Namgis Treatment Centre appreciates the good work you do in helping
those reaching out. We continue to seek program improvement and welcome
suggestions of how we can better serve the referral process.
In Care and Respect
Patrick Davis
NTC Program Manager
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Namgis Treatment Centre
‘Namgis Substance Abuse
Treatment Centre Society
P.O. Box 290
Alert Bay B.C., V0N 1A0
Ph: (250) 974-5522
Fax: (250) 974-2257
TO ALL REFERRAL WORKERS: CHECKLIST
To confirm that the Checklist has been reviewed by the Referral worker and
the Client, signatures are required at the bottom of page # 2 of this
Checklist. (**Please return pages 1 & 2 of the Checklist**)
Prior to Submitting this Application package please ensure that your
client/s meet the following criteria listed below:
□
□
□
□
□
□
□
□
□
□
□
□
□
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□
Client must attend a minimum of 6 counseling sessions one (1) per week
prior to the program intake date. Verification of sessions is required in
Application Package.
Client is required to abstain from alcohol for a minimum of 10 days prior to
the intake date.
Date of last use of alcohol? ___________________________________
Client is required to abstain from drugs for a minimum of 10 days prior to
the intake date.
Date of last use of drugs? ____________________________________
Client is required to state all Legal information any omission of Legal
issues can/will be grounds for dismissal from the program.
Clients who have upcoming Legal Pending issues will Not be accepted.
If the Client is Terminated/Self Terminated from the program, the client is
responsible for his/her own travel costs home.
If Client is on Probation, a letter from the Probation Officer stating the
conditions of probation and expected reporting requirements of the client
during the 42 day duration of treatment is required. A copy of the
Probation Order/s is also required to be included with the Application
Package.
Client has NO outside commitments during the 42 day session. (e.g. No
Court appearances, Lawyers, Doctor’s, Dental appointments. Family
responsibilities Etc.)
Client is aware of what is necessary to bring and what not to bring with
him/her when coming to treatment.
Client has committed himself/herself to completing the 42 day program.
Client has read and understands this Application package.
Client/Referral worker have worked together to complete all forms for this
Application package.
As the Referral worker you take the responsibility to ensure that all forms
are complete, and all necessary arrangements are made for your clients,
such as travel, comfort allowance, etc... Signatures are signed where
required, and that the client meets all requirements for this application
package.
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Namgis Treatment Centre
Referral workers please complete the Application package with your client/s.
Please Print legibly. All questions are to be completed in the application package. If no
response is required please enter N/A. Signatures are compulsory where indicated. All
information is important in processing your client’s application.

If your client’s Application Package is INCOMPLETE your client’s application
package will be returned to you for completion.

Namgis Treatment Centre is funded for Status Indians and Inuit clients.

Non Status individuals will be considered pending clients have their own funding
in place to cover their stay at treatment and bed availability.

We are a six (6) week, 15 bed, Co-ed program. (19 and over only)

Individuals who are currently incarcerated can Not apply at this time, he/she can
apply when they have been released into their community for a minimum 30 days.

We limit the number of clients per session with legal orders in place.
(Which include those who are: Court Ordered, Ministry Ordered or on Probation.)

We do not accept clients who are on the Methadone Program.

We do not accept clients who are pregnant due to Medical concerns.
To ensure that you are sending in a COMPLETE Application Package please
use the check list below.
□ Referral Worker Check list, completed and signed by Referral worker and Client
(Pages 4 & 5)
□ Application for Treatment package (Pages 6 – 12)
□ Consent for Treatment (Page 13)
□ Preadmission Medical Evaluation (Page 14)
□ Preadmission Medical Examination (Pages 15-16)
□ TB Screen Test Results (939 Form included in package- Page 17)
□ Chest X-ray is Mandatory if client has a positive result on TB skin test.
□ Copy of Probation order if applicable
□ Suicide Risk Assessment Form (Page 18 & 19)
□ Agreements (Pages 21-25)
Thank you if you have any questions please contact us at the ‘Namgis Treatment Centre.
Ph.: (250) 974-5522 ext. 2131
Fax: (250) 974-2257 or alternate fax: 250-974-2736
*Referral worker signature: _________________________________
*Client signature: __________________________________________
Date: ____________________________________________________
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Namgis Treatment Centre
NAMGIS TREATMENT CENTRE
Application Package
Personal Identification
Application Date: _____/_____/_____
Day
Month
PLEASE PRINT LEGIBLY
Year
Last Name (legal):
Birth Last Name (if different)
(Please Print)
(Please Print)
First Name(s):
Known As:
(Please Print)
(Please Print)
(Nickname):
____________________
Middle Name: ___________________________ Gender: ____ Male ____Female
Personal Health Number (PHN) __ __ __ __ __ __ __ __ __ __ (10 DIGITS)
Birth Date: _____ / _____ / ________
Day
Month
S.I.N. __ __ __ __ __ __ __ __ __
Year
Address: _________________________________ ____________________________________
City:
Telephone #:
Province: _____ Postal Code: ____________
(
) _____________________Cell#:
(
Email: _________________________________ Living On
) __________________________
Off
Reserve
Native Status: ___YES ___ NO ___ INUIT ______________________________________OTHER
Band #: __ __ __ __ __ __ __ __ __ __ Band Name: _______________________
DIGITS)
(10
Ancestry/Nation: _________________________ Treaty # _____________________________
Marital Status:
Single 
Common-law 
Married 
Emergency Contact:
______________Relationship: _________________________
Separated 
Divorced 
Widowed 
Address: _______________________________ Telephone #: _________________________
------------------------------------------------------------------------------------------------------------------------------Referring Counselor Name: _____________________________________________________
Address: ____________________________________________________________________
Telephone: ___________________________ Emergency: _____________________________
Fax: ________________________________ Email: __________________________________
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Namgis Treatment Centre
Personal
 YES  NO
1. Was the client raised on-reserve?
2. Has the client been raised by his/her natural parents?
 YES  NO
3. Does the client state that addictions are a problem to his/her well-being?  YES  NO
4. Does the client state that sobriety is needed in order to change?
 YES  NO
5. Are certain areas of the client’s life affected by substance abuse?
 YES  NO
6. Has there been a death in the family due to substance abuse?
 YES  NO
7. Number of children:
At Home
In Temp Care
In Perm. Care
8. Any concerns about the safety of the children left at home? _____________________
9. Education: Residential Public ___ Gr. Completed
Problems reading  YES  NO
10. Is there a history of physical abuse, or sexual abuse ____ ?
___________________
11. Any other significant events? _____________________________________________
__________________________________________________________________________
Personal Relationship
1. How long has client been involved in present relationship? ____________________________
2. Relationship strengths: ____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. Relationship weaknesses: __________________________________________________
_____________________________________________________________________________
4. Relationship Breakdowns: __________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Comments: ___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Namgis Treatment Centre
Dietary
Food Allergies:
 YES  NO
_________________________________
Eating Disorders:
 YES  NO
_________________________________
Special Diet:
 YES  NO
_________________________________
Does client eat Traditional Foods?
 YES  NO
If not, willing to try?
 YES  NO
Comments: ___________________________________________________________________
_____________________________________________________________________________
Employment
Usual Occupation: _____________________________________________________________________
Current Employment Status:
Full Time 
Part Time 
Laid-off 
Unemployed 
Has your dependency on drugs or alcohol affected your employment status?  YES
If Yes, how?
 NO
__________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Comments: ____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Spiritual/Cultural
Spiritual/Cultural Involvement _____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Is the client involved in any spiritual/cultural activities? __________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Namgis Treatment Centre
Legal
It is Mandatory to complete ALL of the Questions on this page.
* Does your client have any Past Legal issues?  YES  NO What? _________________________
*Does your client have any Present Legal issues?  YES
*Any Probation in the Past  YES
* Any Probation Present  YES
Alcohol or Drug related:
* Federal 
 NO What? _____________________
 NO Length of Supervision: ______________________
 NO Length of Supervision: ______________________
 YES
 NO
Provincial * Date of Release:
/
Day
Alcohol or Drug related:
 YES
/
Month
Year
 NO
Personal Development courses taken while in Institution
____________________________________________________________________________________
Client must be Free from Incarceration 30 days before applying for treatment
Have you been charged in the last seven (7) years with:

A Non Indictable Offense
Yes___ No ___

An Indictable Offense
Yes___ No ___

Both
Yes___ No ___
*Offense: ______________________________________________________________________________
* Any previous convictions?
 Yes
 No If yes, for what? ________________________________
* Any charges pending?
 Yes
 No If, yes, what charge? _____________________________
Any Court Dates Pending?
 Yes
 No If, yes, what date? ______________________________
*License suspension
 Yes
 No If yes, how many __________
* Impaired conviction
 Yes
 No If yes, how many __________
Alcohol or Drug related:
 Yes
 No
* Post-Treatment A/D Counselor and Agency: _________________________________________________
Address: ________________________ City: _________________________ Postal Code: ____________
* Probation Officer: _______________________________________ PO Phone #: _____________________
Address: _____________________________________________
PO Fax #: _______________________
City: __________________________ Postal Code: _____________ PO Email: _______________________
* Referral Worker Initials required ___________ *Client Initials required ____________
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Namgis Treatment Centre
Social/ Support
1. Client’s support network: _______________________________________________________
_____________________________________________________________________________
2. Where does client seek support? _________________________________________________
3. What supports are available to client on discharge? __________________________________
_____________________________________________________________________________
Referral Information: Please check one of the following boxes: □ A& D □ Doctor. □ Nurse
□ CHR □ Social Worker □ Probation Officer □ Mental Health Worker □ Other ______________
Referring Officer:
Referral Date: _________________________
Agency: ______________________________________________________________________
Address: _______________________________ ______________________________________
Telephone #: ___________________________ Emergency #: _________________________
Fax: ___________________________________ Email: _______________________________
Name of A& D Counselor if different from the Referring Officer: ___________________________
Agency: ______________________________________________________________________
Address: ______________________________________________________________________
Telephone: _____________________________ Fax: __________________________________
History of Substance Abuse- Drugs Abused
TYPE
**NOTE: Put a circle around primary drug(s)
of choice.
None
Rarely
Monthly
Weekly
Daily
Age of
First Use
Alcohol ( beer, wine, hard liquor)
Marijuana, Hashish
Inhalants (glue, paint), Sprays - solvents
Cocaine (e.g. crack, coke)
Stimulants/Amphetamines
Opiates-Morphine, Heroin, Dilaudid
Tranquilizers-Ativan, Valium, Librium, Zanax
Hallucinogen – LSD, PCP, dust
Painkillers – Codeine, Percodan, Lalwin
Tobacco – Other
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Namgis Treatment Centre
Abuse History
 YES
1. Have you ever had: DTs, Blackouts, seizures, hallucinations?
Describe:
 NO
__________________________________________________________________
2. Needle use?
 YES
 NO
3. Shared needles?
 YES
 NO
4. Practice safe sex?
 YES
 NO
5. Withdrawal symptoms after stopping? ____________________________________________
_____________________________________________________________________________
6. Have you attended residential substance abuse treatment before?
 YES
 NO
If yes, where/when?
____________________________________________________________________________
Which one/s did you complete? __________________________________________________
Have you previously attended Namgis Treatment Centre? _______________________________
How Many times: ___________________________ When? _____________________________
Alcoholics Anonymous?
A) Involvement
 YES
 NO
B) Sponsor
 YES
 NO
C) Amount of contact
___________________________________
1. Have you received psychiatric services previously?
 YES
 NO
Comments: ____________________________________________________________________
_____________________________________________________________________________
Medical/Psychological
1. Significant Medical Issues? _____________________________________________________
_____________________________________________________________________________
2. Significant Psychological Issues?
_______________________________________________
_____________________________________________________________________________
Presenting Problems
1. Presenting events: ___________________________________________________________
_____________________________________________________________________________
2. Is attendance: Court ordered___ Ministry of Child & Family Services ______ Other
______
3. If ordered, contact: Name _____________________________________________________
Organization: _______________________________________________________
Address: _______________________________________________________
Phone: ________________________ Fax: _________________________
Comments: ___________________________________________________________________
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Namgis Treatment Centre
Client’s Perspectives
1. What are the client’s perceptions of his/her addiction? _______________________________
_____________________________________________________________________________
2. Client’s wants/expectations? ___________________________________________________
_____________________________________________________________________________
3. Other concerns: _____________________________________________________________
_____________________________________________________________________________
Comments: ____________________________________________________________________
_____________________________________________________________________________
Counsellor Perspectives
1. Client’s emotional state: _______________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. Client’s insight: ______________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. Level of client’s motivation:
____________________________________________________
_____________________________________________________________________________
4. Does client have a discharge plan?
 YES
 NO
Comments: ___________________________________________________________________
If the client is Terminated/Self Terminated the Client/Referral worker is responsible for the client/s travel
costs home. (No exceptions allowed)
A Minimum of 6 (Six) counseling sessions 1(One) session per week is mandatory for client/s to attend
before coming to treatment.
Counseling sessions can be with an: A & D Counselor, Healing Circle, An Elder, AA meeting, NA
meeting,
Support group, etc.
Date of Sessions and with whom:
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
5. ___________________________________________________________________
6. ___________________________________________________________________
*Counselor Signature: _________________________________________________________
*Client Signature: ____________________________________________________________
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Namgis Treatment Centre
‘Namgis Treatment Centre
Consent for Treatment
I, ___________________________, agree to enter the ‘Namgis Treatment Centre for the purpose of treating my
alcohol/drug dependency problems.
I agree to attend a Minimum of six (6) counseling sessions prior to attending treatment.
I also agree to be involved in Alcohol/Drug Outpatient Counseling after attending the ‘Namgis Treatment Centre.
I understand the explanation of the above points of the “Namgis Treatment Centre Program, I therefore consent to
undergo treatment at the Namgis Treatment Centre.
Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Consent for the Release of Confidential Information
I hereby give my permission for staff of the ‘Namgis Treatment Centre to contact:
Referral Worker ___ Social Worker ___ Probation Officer ___ Lawyer ___
Other: ______________________________________________________________________________
For information to be released which shall be limited to:
(i.e. progress during treatment, progress reports)
______________________________________________________________________________
*CLIENTS SIGNATURE: ___________________________________ DATE: ___________________
*REFFERAL WORKERS SIGNATURE: _________________________________________________
PRINTED NAME OF WITNESS/REFERRAL WORKER: __________________________________
REFFERAL AGENCY: _____________________________ TELEPHONE: ____________________
ADDRESS: ____________________________________ POSTAL CODE: _____________________
ALTERNATE CONTACT PERSON: ___________________________________________________
(If possible, for confirmation or admission processing only – not to be included in the release of confidential
information prior to, during, or after treatment.)
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Namgis Treatment Centre
‘NAMGIS TREATMENT CENTRE
PRE-ADMISSION MEDICAL EVALUATION
Date: ____________________________
Client’s Name: _____________________________
Please Print
Date of Birth: ________ ________ _______
Day
Month
Year
Personal Health Number: __ __ __ __ __ __ __ __ __ __ __
A & D Counselor’s Name: ______________________________
Please Print
Referral Agency: _____________________________________
Phone: (______)__________________________
Fax: (_____)____________________________
CLIENT RELEASE OF MEDICAL INFORMATION
I, ____________________________________, hereby request and permit my physician, to release medical facts
and assessments about me to ‘Namgis Treatment Centre and the above named A & D Counselor. The photo-copy
fax of my signature on this form is as valid as the original.
*CLIENT’S SIGNATURE: _________________________________________
DATE: _________________________________________________________
TO THE PHYSICIAN:
The above client is to be medically assessed as a potential participant in our six (6) week residential life
skills program. Our program is designed to help people who acknowledge their drinking or drug use has
interfered with their effective functioning and who are physically and mentally ready to participate in a
program of intense counseling activity. As a counseling program and not a psychotherapy program the
‘Namgis Treatment Centre requires a client to have a complete physical examination prior to admission.
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Namgis Treatment Centre
‘Namgis Treatment Centre
Pre-Admission Medical Examination
(Please Print Legibly)
Date of Exam: ____________________________
Name: _______________________________Date of Birth: _______ _______ _______
(Please Print)
Day
Month
Year
Are you the family doctor for the above individual stated? □ Yes □ No
1. A) Date of last alcohol use:
__________ __________ __________
Day
Month
Year
B) Smoker Yes _____No____
Date Quit ___ ______ ___
Day Month Year
Current ______ per day
2. Date of last psychoactive drug use: ___________________ __________________________
(Please Print)
Day Month Year
Name of Drug
_______ __________ _________________________
Day Month Year
Name of Drug
3. Current Medications: Dosage, Frequency and reason for Medication (Please Print Legibly)
___________________________________________ _______________________________________________
__________________________________________________________________________________________
___________________________________________ _______________________________________________
4. Previous or current psychiatric condition: ________________________________________
5. A) Current medical condition (s) list: ___________________________________________
____________________________________________________________________________
B) Any previous/current conditions?
______________________________________________________________________________
6. Medical problems to be followed while in treatment (M.D. is available for follow up). Please give
details:
______________________________________________________________________________
7. Is this patient Pregnant?
8. TB Screen:
Yes ______
No _______
Not applicable _______
Please use the 939 form provided in your application package.
If Mantoux Skin Test is Negative – No further action is necessary.
If Positive result (Past or Present) Chest X-ray is required. Please submit results of Chest X-ray.
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Namgis Treatment Centre
Past/Current History:
9. Is there any disorder of the following?
Please Circle
a. Hair, skin, nails (especially current or recent infestations or infections
b. Ear, nose, throat
c. Musculo skeletal system
d. Blood, lymphatic system
e. Cardio vascular system
f. Respiratory system
g. G.I. system
h. G.U. system
i. CNS – especially hx of seizures
j. Past history of TB
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
If yes to any of the above please give details:
_________________________________________________________________________________________
_________________________________________________________________________________________
10. Family History:
Alcohol/Drug Problem
Psychiatric History
Adopted
11. Physical Examination:
Ht. __________ Wt.__________ B.P. __________ P. __________
a. Appearance
b. E.N.T.
c. Hair, skin, nails
d. Reticuloendolhehial system
e. Musculo skeletal system
f. Thyroid
g. Cardio vascular system
h. Respiratory system
j. Central nervous system
k. Evidence of sexually transmitted disease
l T.B. test
m. Dental
Normal
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
YES _____ NO _____
YES _____ NO _____
YES _____ NO _____
Abnormal
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
12. Give details to Re: abnormal notations:
_____________________________________________________________________________________________
This client should not require acute medical care at time of Treatment Centre admission. Diseases are to be under
control as much as possible, especially communicable diseases.
I have examined this client and find him/her to be fit to attend residential treatment.
PHYSICIAN’S SIGNATURE: __________________________________________
PRINTED NAME: ____________________________________________________
ADDRESS: __________________________________________________________
PHONE: (________)___________________________________________________
FAX: (________) _____________________________________________________
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Namgis Treatment Centre
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Namgis Treatment Centre
Namgis Treatment Centre
To be completed by Referral Worker only:
Client Name: __________________________
Suicide Risk Assessment Form
1. Have you thought about killing yourself in the last 3 months?
Yes
No
2. Have you ever thought about killing yourself or attempted to kill yourself before?
Yes
No
If either of these (question #1 or #2) is yes then you must go on to ask the following questions
and assess risk factors.
3. On a scale of 1 – 10 where 10 is absolutely unbearable, how much pain are you in?
(1 being lowest level of pain and 10 being the highest level of pain)
_______________________________________________________________________________
_______________________________________________________________________________
__________________________________________________________
4. If you are thinking of killing yourself do you have a plan?
_______________________________________________________________________________
_______________________________________________________________________________
__________________________________________________________
5. If so, what is your plan? Or have you thought about how or when you may make your attempt
(Notice: immediacy, certainty, lethality & accessibility)
_______________________________________________________________________________
_______________________________________________________________________________
__________________________________________________________
6. What are some reasons to stay alive? Who can you talk to? (Or what are some things you
were looking forward to before this pain?)
_______________________________________________________________________________
_______________________________________________________________________________
__________________________________________________________
***If appropriate further explanation can be done by asking, “Tell me more about that….”
***Important to notice verbal and non-verbal messages being communicated & note them.
Risk Factors:







Addiction
Child Abuse
Childhood Abuse
Spouse Abuse
Depression
Increased Isolation
Preoccupation with
death
Namgis Treatment Centre






Hopelessness
Impaired Judgment
Recent Loss
Self Injury
Lack of social support
Previous MH/SA
hospitalization
 History of mental health
concerns
 Family history of
suicide/violence
 Previous Suicide attempt
 Self-destructive or risktaking behaviour
 Other:______________
_
18
Please Circle Level of Risk:
Pain (1 – 10)
Plan
Low
Low Risk
Level 1 – 5/10
No specific plan
No available means
Aren’t certain want to die
Medium
High
Medium Risk
6 – 8/10
Planned but not
immediate risk
Plan has possibility of
intervention
Aren’t sure want to die
High Risk
9 – 10/10
Immediate
Date/time planned &
prepared
Referral Workers task:
1. Validate – focus on strengths and personal resources
2. Identify supports/resources (with phone numbers)
3. Risk Specific Responses
Low Risk
 Action plan



 ___________________
 ___________________
1. Concrete Goal
2. Resource
___________________
3. Another Meeting
 ___________________
1. Promise
2. Suicide Specific
Resource
3. Another Meeting
 ___________________
 ___________________
Medium Risk



No Harm Agreement
24 hour supervision available if needed
Suicide means removed from home
___________________
 ___________________


High Risk
 Emergency referral to suicide specific resource or escort to
Hospital or call ambulance/police for assistance if needed
 24 hour supervision in place
 Suicide means removed from home
4.
5.
6.
7.
Consult with Supervisor and Document
Inform Parents/Family
Follow-up with Longer Term Resources
Take Care of Yourself







***To protect you from any legal consequences it is essential you always record your suicide risk
assessment on paper and consult with a mental health professional when risk is medium or high.***
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Namgis Treatment Centre
‘Namgis
Substance Abuse
Treatment Centre Society
P.O. Box 290,
Alert Bay B.C., V0N 1A0
Ph.: (250) 974-5522
Fax: (250) 974-2257
Namgis Pre-treatment Agreements
The Pre-treatment Agreements:
 Consent for Treatment
 Client Charter of Rights, Responsibilities and Agreements
 Confidentiality Oath
These must be read, and signed by the Referral Worker and the Client/s together.
Please return the Agreements to the Namgis Treatment Centre as soon as possible.
Any questions or for further information, please contact me @ 250-974-5522 ext. 2131 or
By email MaryH@namgis.bc.ca
Mary Hunt
Namgis Treatment Centre
Intake Coordinator
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Namgis Treatment Centre
CONSENT FOR TREATMENT
I _____________________ (Name of Client) understand that my participation in the Substance
Abuse Program at the Namgis Treatment Centre requires that I am:



Aware that the Namgis Treatment Centre program is a continuous six- week program,
which begins upon my arrival and ends following the completion ceremony.
Aware that there is a schedule of events and activities which will require my full
participation, and
Aware that if I am UNWILLING to participate fully, I may be asked to leave.
I understand for the client and staff to work effectively, the treatment program will include:






Counseling assessments and treatment plans
Arts and crafts, recreational activities, and ceremonies
Group therapy sessions/life skills training/sessions with elders/assignments
Alcoholic Anonymous/Narcotics Anonymous meetings
Contact with my referral sources, and
Maintenance of confidential client records as stated in the Privacy Act
I understand that applicants have been referred from NNADAP, Friendship Centres, Social
Workers, Doctors, Detox, Employers, Alcohol and Drug Counselors, and Parole.
I understand treatment is a continuum. Therefore, I agree to be involved with after-care.
I am aware that according to the Family and Child Services Act, staff at Namgis Treatment
Centre are required to report to the appropriate authorities any information received regarding
the abuse of any individual presently under the age of nineteen (19).
I understand the explanation of the above points and the above named Agency’s program and
guidelines and I therefore, consent to undergo treatment at the Namgis Treatment Centre.
I am aware that whenever people gather, such as at home communities, social and spiritual
functions, family and treatment programs, etc., there may be identified and unidentified sexual
offenders present. This is also true of Namgis Treatment Centre.
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Namgis Treatment Centre
I also understand that I can withdraw or amend my consent to the release/request of information
at any time.
*Client’s Signature:
Date:
*Witness Signature:
Date:
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Namgis Treatment Centre
‘Namgis
Substance Abuse
Treatment Centre Society
P.O. Box 290,
Alert Bay B.C., V0N 1A0
Ph: (250) 974-5522
Fax: (250) 974-2257
Namgis Treatment Centre
Client Charter of Rights, Responsibilities and Agreements
1. I acknowledge that I have the right to be treated with dignity and respect.
2. I acknowledge that I have the right to be treated as a unique and valuable
individual in a non-discriminatory manner.
3. I acknowledge that I have the right to begin dealing with my addiction and related
issues in an environment that is safe and free of all forms of abuse.
4. I acknowledge that I have the right and responsibility, to question things that I do
not understand or agree with.
5. I acknowledge that I have the right to accurate and complete information
regarding the extent, nature and limitation of any service that is being provided.
6. I acknowledge that I have the right to make a complaint about something that I
do not agree with, or that makes me uncomfortable.
7. I acknowledge that I am responsible for taking part in the daily scheduled
programming to be on time and to participate fully.
8. I agree not to use alcohol or other drugs while I am participating in this program
– it jeopardizes not only my recovery, but the recovery of others as well.
9. I acknowledge that I am responsible for helping to maintain a safe, drug and
alcohol free environment and agree to let staff know, if I become aware that
anyone is using alcohol or drugs, or making the environment unsafe for others, in
some way.
10. I acknowledge that there are stressors/triggers that may overwhelm me from time
to time if I am overwhelmed or are at risk of harm to myself or others that I will
speak to my one to one worker.
11. I acknowledge that need for guidelines for my relationships with other residents
of the program. I agree that any physical contact that I have with another client in
the program will be appropriate, non-romantic, and non-sexual. I agree that I will
not have ANY physical, sexual or romantic contact with any client in the
treatment program, any staff member, or any community member.
12. I acknowledge that I have the right to be free from all forms of sexual
harassment. I agree that I will refrain from all forms of harassment, including
suggestive remarks and looks.
13. I acknowledge that my reason for coming to the Namgis Treatment Centre is to
concentrate on beginning/continuing my recovery and agree to take care of all
outside issues prior to admission and to focus on my recovery while in the
program.
14. I acknowledge that it is my responsibility to follow the behavior guidelines as
outlines in the program – they have developed for everyone’s comfort and
protection. I acknowledge that if I violate those guidelines, I may be required to
leave the program.
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Namgis Treatment Centre
Namgis Treatment Centre
Client Charter of Rights, Responsibilities, and Agreements
15. I acknowledge that I am responsible for treating the other clients in a fair and considerate
way and agree to strive to treat them the way I wish to be treated.
16. I acknowledge that I am responsible for my own recovery and agree to make every
attempt to begin looking at and thinking about myself and my life, in new ways that are
positive and life affirming.
17. I acknowledge my right to have my confidentiality protected and recognize that I am
responsible to help protect other’s confidentiality. I agree not to tell anyone outside of the
program about people who have been at the Namgis Treatment Centre and agree not to
talk about things that are disclosed in our groups.
Client Name: (Please Print)
*Client Signature:
*Witness:
Date:
Date:
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Namgis Treatment Centre
CONFIDENTIALITY OATH
I, ____________________, hereby swear
the following oath of confidentiality:
I swear, that any confidential
Information that is shared by fellow clients
and, counselors will be held in the Strictest of confidence.
Failing this, I will be subject to the
Disciplinary actions of the
Namgis Treatment Centre.
__________________
* Client Signature
__________________
*Witness Signature
__________________
Date
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Namgis Treatment Centre
Namgis Treatment Centre
Client Checklist
Referral Worker please give this Checklist to your client/s prior to him/her coming to treatment. If your
client/s has/have difficulty reading, please read and review this checklist with your client/s.
Please Bring These Following items with you when attending treatment:

Comfort Allowance (For six weeks.) We strongly suggest Direct Deposit, an ATM may not available.

Personal Identification suggested: Status Card, Birth Certificate, BC ID, PHN card, Driver’s
License, etc.

Please bring loose comfortable clothing such as a jogging suit for your use during exercising.

Personal Medication: Physician prescribed. If possible please have all medication in Bubble
packages for the six- week stay. (All medications are to be handed over to the NTC staff when client
arrives for Treatment)
* Shampoo & Conditioner
 *Toothbrush & toothpaste, and Dental floss  *Comb & Brush
*Deodorant/ Body wash
* Shaving equipment
* Running shoes 
* Appropriate Daily clothing * Slippers
 *Pajamas/robe
* Personal sundries
 *Writing paper/envelopes/stamps *Personal Arts & crafts 

The following are optional:
 Family photos,  Camera,  Dress clothes/dress shoes for graduation,  Travel Mug/Cup or
 Water Bottle
The following items are NOT permitted:
X - Laptop computer X - Personal DVD player/DVD’s
X - CD Player/CD’s X - Cassette Player/Cassettes
X - Alarm clock
X - Video Camera
X - No over the counter medications
X - MP3 Player
X – Personal Phone
X - iPod
X – Radio
X - No hand held Electronic games of any kind
X - No low cut or revealing clothing
X - Absolutely No Junk Food permitted (Chips, pop, gum, candy, etc.)
If any of the above items are brought with client to treatment the item will be handed in upon entrance and
will be return when the client is ready to leave treatment.
If the client travels to treatment with personal vehicle the keys will be handed into a Staff member upon
arrival and the vehicle will remain parked until the end of the Treatment session.
Referral worker please ensure that your client/s has their comfort allowance and return travel
arranged before they attend treatment. Eg. Bus ticket, plane ticket, ferry tickets, etc. Thank you.
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Namgis Treatment Centre