Application of Admission | Crossroads Centre

Crossroads Centre

500 Oliver Rd.

Thunder Bay, ON, P7B 2H1

Telephone: 807.622.2730

Fax: 807.622.7587

www.crossroadscentre.ca

Sister Margaret Smith Centre

301 Lillie St. North

Thunder Bay, ON, P7C 0A6

Telephone: 807.684.5100

Fax: 807.622.1779

www.sjcg.net

Referral To:*
- Pre-Treatment - Crossroads Centre
- Post-Treatment - Crossroads Centre
- Residential Services - Sister Margaret Smith Centre
- Out-patient Services - Sister Margaret Smith Centre
THUNDER BAY INTEGRATED ADDICTION AND MENTAL HEALTH SERVICES
CONSENT TO OBTAIN / RELEASE INFORMATION

The protection of your privacy and the delivery of high-quality care is our priority. In order to best serve you, a group of service providers, all committed to the protection of your privacy, are working together to support your decisions regarding your care. With your permission, we will share information with each other and with other agencies to support you in developing a plan of care that is designed to support your choices and decisions.
The following agencies are part of a service system that is designed to support you in reaching your personal goals.
If you are in agreement for the named agencies and related programs to share assessment, treatment and case management information, please indicate your authorization by checking the box beside each relevant agency.*
- Thunder Bay Counselling Addiction Services, Thunder Bay, ON
- Crossroads Centre Inc. Thunder Bay, ON
- St. Joseph’s Care Group Addiction & Mental Health Services Thunder Bay, ON
- Dilico Anishinabek Family Centre Mental Health and Addictions Services Thunder Bay, ON
- Alpha Court Community Mental Health & Addiction Services, Thunder Bay, ON
In addition, there may be cause to share your personal health information with other care providers and agencies to support you in meeting your personal goals. If you are in agreement for the agencies listed below to obtain/release information with the authorized agencies in Thunder Bay Integrated Addiction and Mental Health Services please Check the box beside each agency indicating your authorization.
Consent to release/request information from the persons/agencies below:*
- EMR (electronic medical records)TBRHSC&SJCG
- Crossroads Centre Inc. Thunder Bay, ON
Having read and understood this form, I hereby authorize the identified agencies of Thunder Bay Integrated Addiction and Mental Health Services to Release/Request Information to/from each other and to/from the persons/agencies listed above. I also understand that I can withdraw my consent in writing at any time and that I can restrict the nature and type of information shared. This consent is considered valid for a period of six (6) months from the date this form was filled out to when it will be reviewed and renewed as required.
Name*
First Name Last Name
Date of Birth*
Reviewed and Witnessed by
First Name Last Name
Date*
Substitute decision maker
First Name Last Name
Date
Relationship
THUNDER BAY ADDICTION AND MENTAL HEALTH SERVICES
GUIDELINES FOR COMPLETING FORM

Clinician / Case Manager will review the Consent to Obtain/Release Information with the client and address any questions/concerns prior to obtaining a signature
Clinician / Case Manager will review the Consent to Service prior to obtaining client signature
Copy of the Consent to Service and Consent to Obtain/Release Information will be filed on the clients’ record
The receiving agency conducting the initial intake will also provide a copy of their agency’s privacy statement
Client Information
Name*
First Name Middle Name Last Name Last Name at Birth
Email
Enter Email Confirm Email
Date of Birth*
Age*
Gender*
- Male
- Female
- Other
Health Card Number
Mailing Address
Street Address City State / Province / Region ZIP / Postal Code
- NFA
Home Phone #
Other Phone #
Call Allowed:
- Yes
- No
Message Allowed:
- Yes
- No
Preferred Language:
Emergency Contact
Name
First Last
Relationship to Applicant
Phone Number (mandatory)*
Referent Information
Date of Referral
Referring Agency
Name of Referent
First Last
Email Address
Enter Email Confirm Email
Agency Address
Street Address ZIP / Postal Code
- NFA
Fax #
Client Type - Please Checkmark
- Client- Alcohol/Drug
- Client- Alcohol/Drug/Gambling
- Client- Gambling
- Family member of Alcohol/Drug Client
- Family member of Alcohol/Drug/Gambling Client
Ethnicity - Ethnic or cultural Identity
Primary
Status #
Band
Please Checkmark in Each Section that Best Fits
Treatment Mandated/ Required By:
- None
- Choice between treatment or jail
- Condition of probation/parole
- Child Welfare Authority
- Condition of employment
- Condition of school
- Condition of family
- Other
Other:
Legal Status:
- No problem
- Awaiting trial\sentencing
- On probation
- On parole
- Incarcerated
- Other
Start Date
End Date
Start Date
End Date
Other:
Relationship Status:
- Married/partnered/common-law
- Single (never married)
- Widow or widower
- Separated or divorced
Spouses Name
First Last
Employment Status:
- Employed full-time (includes self-employment)
- Employed part-time
- Unemployed (looking for work)
- Student\ retraining
- Program
- Disabled (not working)
- Not in labour force
- Retired
Highest Level of Education
- No formal schooling
- Some primary school
- Primary school
- Some high school
- Completed high school
- Some college
- Completed college
- Some university
- University degree
Income Source:
- Disability insurance (WSIB)
- Employment
- Employment insurance
- Family Support
- None
- ODSP
- Ontario Works
- Other Insurance
- Retirement
- Other
Other:
Parenting
- Yes, with 1 or more child aged 0-6 years
- Yes, with no children aged 0-6 years
- Children in care of others
- No Children
Substance Use & Gambling History
Presenting Problem Substances:
Major Substance
Substance Used
Major Substance - Frequency in the Last 30 Days
Age of 1ST Use - Major Substance
Age regular use began - Major Substance
1ST Other Substance
Substance Used
1ST Other Substance - Frequency in the Last 30 Days
Age of 1ST Use - 1ST Other Substance
Age regular use began - 1ST Other Substance
2ND Other Substance
Substance Used
2ND Other Substance - Frequency in the Last 30 Days
Age of 1ST Use - 2ND Other Substance
Age regular use began - 2ND Other Substance
Other Substances used in the Past 12 Months (Checkmark all that apply)
- Select All
- Alcohol
- Amphetamines
- Barbiturates
- Benzodiazepines
- Cannabis
- Cocaine
- Crack
- Ecstasy
- Glue/Inhalants
- Hallucinogens
- Heroin\Opium
- Methamphetamines (Crystal Meth)
- Other Psychoactive drugs
- Over-the-counter codeine products
- Prescription Opioids
- Steroids
- Tobacco
- Unknown
- None
Gambling activities engaged in the Past 12 Months
- Select All
- Bingo - live/TV/radio
- Slot machines
- VLT’s/ other gaming machines
- Casino- Card/Table Games
- Non-Casino Card/Table Games
- Horse races-live/off-track
- Sports betting (including Pro Line)
- Lottery tickets
- Instant win/scratch tickets (i.e. break open, pull tab, Nevada strips)
- Internet Gambling
- Gambling with Stocks/Options/Commodities/Real estate
- Betting on games of skill i.e. pool, pitching pennies
- Betting on the outcome of events
- Other
- None
- Unknown
Other:
Is Gambling Identified as a Problem?
- Yes
- No
Health Status/Problems
Visual impairment:
- Yes
- No
Hearing impairment:
- Yes
- No
Mobility/ physical impairment:
- Yes
- No
Pregnant:
- Yes
- No
- Unsure
Non-medical intravenous drug use:
- Never injected
- Injected prior to one year
- Injected in last 12 months
Reason for most recent hospitalization:
Date
Diagnosed with a mental health problem by a mental health professional:
- within the past 12 months
- within lifetime
Most recent diagnosis
Hospitalized for a mental health problem?
- within the past 12 months
- within lifetime
Received counselling/support/treatment for a mental health, emotional, behavioural or psychological problem from a community mental health program or professional?
- currently
- within the past 12 months
- within lifetime
Name of current service provider
Contact information for service provider
Health Conditions
Please check all that apply:
- Allergies
- Blood pressure problems
- Cancer
- Chronic pain
- Diabetes
- Eating disorders (anorexia, bulimia, over eating)
- HIV/AIDS
- Heart disease
- Hepatitis A
- Hepatitis B
- Hepatitis C
- History of head Injuries/concussion
- History of seizures/epilepsy
- Jaundice
- Kidney disease
- Lice/scabies
- Liver diseases
- Menstrual/menopausal difficulties
- Pancreatitis
- Respiratory
- STD (syphilis, gonorrhea, chlamydia, Herpes)
- Stomach/gastrointestinal problems
- Thyroid problems
- Tuberculosis
Provider of Primary Health care (doctor, nurse practitioner, health clinic):
Contact information for provider of health care:
Prescribed Drugs
On Methadone or Suboxone:
- Yes
- No
Prescriber:
1. Prescribed Drug:
1. Prescriber & Phone #:
1. Prescription Details:
2. Prescriber & Phone #:
2. Prescribed Drug:
2. Prescription Details:
3. Prescriber & Phone #:
3. Prescribed Drug:
3. Prescription Details:
USE THIS SPACE TO PROVIDE MORE DETAIL REGARDING HEALTH STATUS:
Referents Complete
Referral Information:
What circumstances have made the client request treatment at this time?
What supports are you providing? How long have you been working with this client? Is therapy/counseling on going?
What supports does the client have access to in the community? What supports/services has the client accessed to date? (If the client has not accessed services please explain why)
Treatment History
Has the client previously tried to quit or cut down on their substance use or gambling?
- No
- Yes
How many times?
What were the circumstances that caused the client to make changes with his/her use during these times?
What has been the longest period of non-using? What did the client find helpful during those periods?
What do you identify as the reasons for returning to drinking/drug using/gambling?
What has been the longest period of non-using? What did the client find helpful during those periods?
What is the client’s current substance use or gambling goal?
- quit all substance use/gambling
- maintain abstinence
- other
- cut down on
- make no changes
Other:
Cut down on:
Previous addiction treatment
- No previous treatment attempts
- Yes, FILL IN QUESTIONS BELOW
1. Name of Facility
1. Date
1. Type of Treatment
1. Completed?
2. Name of Facility
2. Date
2. Type of Treatment
2. Completed?
3. Name of Facility
3. Date
3. Type of Treatment
3. Completed?
USE THIS SPACE TO PROVIDE MORE DETAIL REGARDING TREATMENT HISTORY:
Emotional Health
PLEASE ANSWER YES OR NO AND PROVIDE INFORMATION ON HOW THE CLIENT HAS COPED AND WHAT SUPPORTS HAVE BEEN UTILIZED
Anxiety- tension, nervousness fears / phobias
- Experienced in the last 90 Days
- Experienced in lifetime
Supports/Coping Skills Used
Depression- grief, losses, isolation
- Experienced in the last 90 Days
- Experienced in lifetime
Supports/Coping Skills Used
Eating disorders- starving on purpose, binging/purging
- Experienced in the last 90 Days
- Experienced in lifetime
Supports/Coping Skills Used
Sexual abuse / sexual assault
- Experienced in the last 90 Days
- Experienced in lifetime
Supports/Coping Skills Used
Physical, emotional, mental abuse
- Experienced in the last 90 Days
- Experienced in lifetime
Supports/Coping Skills Used
Suicide- suicidal thinking, attempts, self-harm behaviour
- Experienced in the last 90 Days
- Experienced in lifetime
Supports/Coping Skills Used
Cognitive- difficulty tracking , concentrating, focusing
- Experienced in the last 90 Days
- Experienced in lifetime
Supports/Coping Skills Used
Anger- assaults, aggressive behaviour
- Experienced in the last 90 Days
- Experienced in lifetime
Supports/Coping Skills Used
Other trauma ( deaths, accidents, other traumatic events)
- Experienced in the last 90 Days
- Experienced in lifetime
Supports/Coping Skills Used
Other Potentially Excessive Behaviours
Please answer all relevant sections. Provide details in the space provided. (Ie. Amount of time spent doing this activity, negative life impact, causes financial strain, topic of arguments with loved ones).
Shopping (excessive money spending)
Details:
Internet overuse (surfing, chatting, blogging, social networking)
Details:
Video Gaming (computer or home systems, online)
Details:
Eating Disorder (starving on purpose, binging purging)
Details:
Sex (pornography, excessive masturbating, visiting sex trade workers, preoccupation with sexual thoughts)
Details:
Other
Details:
USE THIS SPACE TO PROVIDE MORE DETAIL REGARDING EMOTIONAL HEALTH (INCLUDE ALL MENTAL HEALTH DIAGNOSIS DETAILS):
Family/Supports
What community is the client originally from?
Childhood Experiences:
- Substance abuse
- Witness to domestic violence
- Emotional, physical or sexual abuse
- Foster Care
- Neglect
- Divorce/separation of parents
- Death of a parent
- Happy home life
How does the client describe the current relationship with his/her family of origin?
Relationship Experiences:
- Never been in a relationship
- Affairs
- Mental health issues of partner
- Difficulties talking about feelings
- Violence/abuse
- Solid/supportive relationship
If the client is currently in a relationship, does the partner struggle with any addiction issues? Please describe.
Does the client have any children?
- Yes
- No
If yes, who has custody of the children? What is the nature of the relationship with the children?
USE THIS SPACE TO PROVIDE MORE DETAIL REGARDING FAMILY, CHILDREN, AND SUPPORTS:
Employment/Education/Legal
Current or last occupation?
Does the client have EAP in the workplace?
Does the client have a history of learning disabilities or problems?
- Yes
- No
If yes, what type:
Are there any literacy issues?
- Yes
- No
USE THIS SPACE TO PROVIDE MORE DETAIL ON EDUCATION & EMPLOYMENT:
Legal
Any current charges?
- Yes
- No
When is the next court date?
If yes, are you on bail?
- Yes
- No
What are the charges?
Are you on the Sex Offender Registry?
- Yes
- No
Do you have any no contact orders?
- Yes
- No
Have you, or are you currently banned from an emergency shelter?
- Yes
- No
If on probation or parole:
What charges is the client on probation for?
If on probation or parole:
Probation or parole officer’s name & contact info:
Past Offenses (check all that apply):
- Theft / possession of stolen property
- Drug charges
- Weapons offenses
- Robbery
- Arson
- Impaired driving
- Murder / manslaughter, criminal negligence causing death
- Parole / probation violations
- Forgery
- Burglary, break & enter
- Assault
- Sexual assault / incest
- Willful damage / mischief
- Other – (specify)
Other:
USE THIS SPACE TO PROVIDE MORE INFORMATION ON LEGAL:
Name of Client
First Last
Date
Name of Counsellor
First Last
Date
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Crossroads Centre

Sister Margaret Smith Centre

THUNDER BAY INTEGRATED ADDICTION AND MENTAL HEALTH SERVICES CONSENT TO OBTAIN / RELEASE INFORMATION

THUNDER BAY ADDICTION AND MENTAL HEALTH SERVICES GUIDELINES FOR COMPLETING FORM

Client Information

Emergency Contact

Referent Information

Ethnicity - Ethnic or cultural Identity

Please Checkmark in Each Section that Best Fits

Substance Use & Gambling History

Health Status/Problems

Health Conditions

Prescribed Drugs

Referents Complete

Treatment History

Emotional Health

Other Potentially Excessive Behaviours

Family/Supports

Employment/Education/Legal

Legal

THUNDER BAY INTEGRATED ADDICTION AND MENTAL HEALTH SERVICES
CONSENT TO OBTAIN / RELEASE INFORMATION

THUNDER BAY ADDICTION AND MENTAL HEALTH SERVICES
GUIDELINES FOR COMPLETING FORM