Esquao© Healing Lodge
Transcription
Esquao© Healing Lodge
Esquao© Healing Lodge Is our aftercare facility that provides a healing environment to our women in the surrounding community. This 20 bed facility is located in St. Albert, AB. Esquao’s current programs are focused on giving women independence by providing role models, skills development, and guidance on how to achieve their life goals. Our Partners: Esquao© Healing Lodge The programs delivered are focused on the Cultural Role of Women, financial education, leadership development, and advocacy. They will focus on continued recovery and healing with significance placed on Aboriginal women’s health determinants and the road to independence. An aftercare facility that provides a safe environment for women to continue their recovery process through traditional healing and culture. Esquao Healing Lodge 21 Meadowview Drive St. Albert, AB T8N 2R9 Phone: 780.458.1884 Fax: 780. 459.1876 E-mail: [email protected] www.poundmakerlodge.com Esquao© Healing Lodge Esquao© Healing Lodge Program Components: Poundmaker’s Lodge Treatment Centres are known as Canada’s first addictions treatment centre specifically for Aboriginal clients. It is important to note that while our program focuses on Aboriginal culture and spirituality, its principles are universal. Clients from all cultures, traditions and faiths are welcome. Application for Admission: Application form completed by client and/or referral Medical form to be completed by physician Admission Criteria: All legal, medical, educational, employment, and child care services must be dealt with prior to admission. Must be 18 years of age or over Free from all mind-altering substances while a resident. No mood-altering substances are approved for use while in staying at Esquao Healing Lodge. Clients stabilized on a current methadone program are approved on a case-by-case basis. Financial Requirements: For clients residing in Alberta: $40/day For clients outside of Alberta: $150/day For clients outside of Canada: $250/day Esquao© Independence Program The Institute for the Advancement of Aboriginal Women (IAAW) will be delivering the programming for the women staying at the Esquao Healing Lodge. IAAW’s goal is to help revive the women’s strength, wisdom and vision of the future by providing the skills, teachings and opportunities to improve themselves personally and professionally through the Esquao house. The programming will include topics such as: Self Discovery Money Management & Financial Literacy Facing Fears Conflict Resolution Building healthy, safe relationships The Medicine wheel teaches us that in order to live a healthy life we must have balance in the four dimensions of ourselves: the mental, the physical, the emotional and the spiritual. It is our belief that addiction destroys these dimensions and the only effective method of recovery is a holistic approach. Our program combines traditional Aboriginal spirituality with 12 Step Programs and information lectures, to help clients restore balance to their lives. Clients reconnect with their culture, spirituality and themselves through sweatlodge ceremonies, smudging ceremonies, and sweetgrass ceremonies with the guidance of an onsight cultural advisor and elder. The clients also participate in our annual cultural engagement activities such as; Métis Festival, round dance and pow wow. All activities at the Esquao© Healing Lodge are conducted with an emphasis placed on a deep respect for Aboriginal natural laws, traditions and values. Esquao© Healing Lodge This 16 bed women’s residential facility is located in St. Albert, AB. The program will focus on continued recovery and healing with significance placed on Aboriginal women’s health determinants and the road to independence. The Esquao © Healing Lodge will Esquao© Healing Lodge St. Albert, AB engage clientele from the First Nations, Métis and Inuit communities and those who may feel a culturally based program can support their healing and recovery. 16 beds Females only Long term stay ie up to a year Must be 18 years of age or older Free from all mind-altering substances while a resident Clients stabilized on a current methadone program are approved on a case-by-case basis. The Medicine Wheel For clients residing in Alberta: $40/day For clients outside of Alberta: $150/day The Esquao© Healing Lodge is part of the Poundmaker’s Lodge Treatment Centres broader commitment to initiatives that assist and engage the Aboriginal community to achieve increased health Esquao© Healing Lodge outcomes. The facility will provide ongoing elder and cultural supports as well as psychological supports utilizing an Aboriginal therapeutic community model which will allow women to make a difference in their communities. Ph: 780.458.1884 Fax: 780.459.1876 St. Albert, AB WWW. POUNDMAKERLODGE.COM POUNDMAKER’S LODGE TREATMENT CENTRE- Esquao Healing Lodge (Mailing Address) Box 34007, Kingsway Mall Post Office Edmonton, AB T5G 3G4 Website: www.poundmakerlodge.com Phone: (780) 458-1884 Fax: (780) 459-1876 Toll Free: 1(866) 458-1884 Application for Admission 1. Application Form completed by client and/or referral. 2. Medical Form to be completed by physician. Admission Criteria 1. All legal, medical, educational, employment, and child-care services must be dealt with prior to admission so as not to interfere with your treatment program. 2. Must be 18 years of age or over. 3. Free from all mind-altering substances for a minimum of 72 hours prior to admission date. 4. Clients stabilized on a current methadone program are approved on a case-by-case basis, please contact the admissions department. Financial Requirements 1. For clients residing in Alberta (must provide a current and valid Alberta Health Care number on the application form); Treatment service charge of $40 per day. Must provide a written confirmation letter from the agency approving the treatment service charge OR provide a certified check, money order or bank draft for the full amount upon admission for treatment. 2. For clients residing in Canada (excluding Alberta); Treatment service charge of $150 per day. Must provide a written confirmation letter from the agency approving the treatment service charge OR provide a certified check, money order or bank draft for the full amount upon admission for treatment. 3. For clients outside of Canada; Treatment service charge of $250 per day. Must provide a written confirmation letter from the agency approving the treatment service charge OR provide a certified check, money order or bank draft for the full amount upon admission for treatment. What to Bring An ankle-length nightgown (ladies), an ankle-length skirt (ladies) for ceremonies, toiletries (soap, shampoo, etc.), proper footwear and clothing for recreational activities, appropriate swimwear for swimming (no two-piece or see through). If applicable, please bring enough of your prescription medications (preferably in blister packs) to last the length of your treatment. 1 Revised January 2012 Application for Admission Which Program Are You Applying For? (Please check mark only one box below) 42 Day Drug / Alcohol Program 42 Day Gambling Program 14 Day Follow-Up Program (*Must have previously completed a residential treatment program and have maintained sobriety since completion) Esquao Healing lodge Personal Information First Name: Last Name: Other Name Used: Other Last Name Used: Mailing Address: City / Town: Province / State: Postal / Zip Code: Home Phone: Cell Phone: Date of Birth: Month / Day / Year Age: Gender: Male (Please Circle) Marital Status: Single Married Divorced Separated Widowed Ethnicity: Status Non-Status Metis Inuit Non-Aboriginal Treaty Status On-Reserve Off-Reserve Not Applicable (Please Circle) (Please Circle) (Please Circle) Female Common-Law Band Name and 10-Digit Treaty Number: AB Health Care Number: SIN Number: Education: Occupation: If prescriptions are required, how will they be paid for? (ie. SFI Recipient Number, Blue Cross Number, etc.) Next of kin to be notified in case of emergency: Relationship to applicant: Phone Number: Full Address: 2 Revised January 2012 Referral Worker Information (to be completed by referral, if no referral worker please write “Self” and skip to next section of Application) Name of Referral: Title: Agency Name: Agency Address: City / Town: Province / State: Postal / Zip Code: Agency Phone: Agency Fax: Additional Information (to be completed by referral and applicant) Would you be coming to treatment under one of the following conditions listed below? (please circle) * Federal: Parole * Provincial: Probation Other: Statutory Release Unescorted Temporary Absence Recognizance Conditional Sentencing Order Temporary Absence Temporary Release Child Welfare Employment Reasons Not Applicable If applicable, what is your offence (s): Name of Probation / Parole Officer: Address, Phone and Fax Number: (* All legal papers to be submitted along with application form) Details of any previous treatment for addictions: Approximate Date: Where (Institution / Agency): Approximate Date: Where (Institution / Agency): 3 Revised January 2012 Approximate Date: Where (Institution / Agency): Motivation for entering treatment: Please list the names of any substances used, how long you have been using, and when last used: Substance: For how long? Last used: Substance: For how long? Last used: Substance: For how long? Last used: Substance: For how long? Last used: Medical Information If you are currently taking any medications, please list the names of medications and what it is taken for: Medication: Taken for: Medication: Taken for: Medication: Taken for: Health Problems: Suicidal Behavior (Thoughts, Previous Attempts): 4 Revised January 2012 Referral Recommendations (to be completed by referral) Special needs / circumstances that may affect client’s treatment: Referral’s assessment of the applicants motivation for entering treatment: It is the policy of this treatment program that any person being admitted for treatment must be free of alcohol and all illicit substances for a period of 72 hours prior to admission. I understand and agree to accept the treatment program as prescribed as well as adherence to all treatment house rules. Applicant’s Signature Referral’s Signature Date of Application 5 Revised January 2012 POUNDMAKER’S LODGE TREATMENT CENTRE- Esquao Healing Lodge (Mailing Address) Box 34007, Kingsway Mall Post Office Edmonton, AB T5G 3G4 Website: www.poundmakerlodge.com Phone: (780) 458-1884 Fax: (780) 459-1876 Toll Free: 1(866) 458-1884 Medical Information (to be completed by a physician) Note: This medical information is used as part of an application for admission to treatment at Poundmaker’s Lodge Treatment Centre. Your patient is responsible for any fees associated with this service. No mood-altering substances are approved for use while in treatment at Poundmaker’s Lodge, including but not limited to benzodiazepines, opiods, and barbiturates. Full Name of Patient: AB Health Care Number: Name of Physician: Office Phone: Office Fax: Substance Abuse History (including alcohol, illicit substances, IV drug use, withdrawal symptoms, etc.) Current Medications; please list the names of medications, dosages and what it is taken for: Medication: Dosage: Taken for: Medication: Dosage: Taken for: Medication: Dosage: Taken for: Allergies: 6 Revised January 2012 Is This Patient Pregnant? If so, how far along? Any complications? Communicable Diseases: Psychiatric History: Special Dietary Requirements: Physical Examination: Height Weight: BP: Pulse: Physical Notes (ears, nose, throat, skin, lungs, heart, etc): Additional Comments: Physician’s Signature 7 Date Revised January 2012