CHECKLIST ADMISSION/EXIT PROCESSES

Transcription

1 Central Addiction Intake Referral Checklist & Process FOR REFERRING AGENTS MAKING REFERRALS TO: PACIFICA (co-ed Treatment Program), CENTRAL CITY LODGE (ARP) (STLR men only) NEW DAWN (STLR - women only), TOGETHER WE CAN (STLR men only) the following steps must be completed; all documentation must be submitted to the Central Intake Team by fax or CHECKLIST Complete all sections of the Comprehensive Assessment V3 (CAV#) with the client. Counsellor/Case Manager completes the Addiction, MH, Psych/Soc/Spirit, Client Perspective, HONOS & Summary portions of the CAV3 Nurse/Doctor completes the Health & Systems Review portions The CAV3 replaces all referral documents for the Residential Tx/STLR Programs noted above. Discuss the release of the Comprehensive Assessment to the Intake Worker and other Tx/STLR program(s), as the referral(s) will warrant. Ensure the client agrees with all the information collected and sent. No need to print the Assessment when it is completed. Client s Doctor completes the Pharmacy Intake Form (attached), & includes information re: client s current, required medications. Client s Doctor faxes this completed form to the Central Intake Team. Complete MSD Funding Verification form, or other applications for Income Support as warranted (eg: Accommodation Fee Subsidy, Employment Insurance). A VCH Accommodation Fee Subsidy Application is attached, in order to fast-track VCH clients who require AFS funds to access residential Tx/STLR services. If you are referring from a different health authority & your client requires AFS funds, you will need to use your health authority s AFS Application. Nurse or Doctor: complete a TB Test or Chest X-Ray and include the results in the referral package. Review the PharmaNet Consent Form with the client before s/he signs it. Nurse or Doctor: print out Pharmanet results from & send both the signed Consent form & Pharmanet results with the referral package. Orient the client to the appropriate program materials and retrieve the clients signature on specific program forms as warranted (eg: program guidelines/outline, what to expect). All program information can be accessed online: Pacifica Central City Lodge New Dawn Together We Can ADMISSION/EXIT PROCESSES 1. Once the referral is made, the client will be placed on the appropriate waitlist(s). The Referring Agent will be notified of approximate wait times & when the client s admission can be facilitated. The client can be placed on short-term notice availability if desired. Clients waitlisted for Pacifica, Central City Lodge or Together We Can maintain weekly check-in calls with Andrew or Stacy to remain waitlisted; clients waitlisted for New Dawn need to maintain weekly check-in calls directly with Chrysalis Society ( ). 2. Central Addiction Intake Clinician will contact the client when a bed becomes available, and notify the Referring Agent via PARIS, phone or . The client will be informed when their admission is scheduled, and when they need to arrive at the Agency. If transportation support is required, the Central Intake Clinician or Referring Agent will organize/coordinate as warranted. Once the client is admitted, the Referring Agent will be notified by phone or of the client s safe arrival. 3. Within two weeks of the client s admission, the Referring Agent will connect with the Residential Team and the client to collaborate on the client s care plan, all goals of which will support the facilitation of a smooth exit and aftercare plan. Two to four weeks prior to the client s exit, the Referring Agent and the Residential Team will confirm the aftercare plan with the client. Consultations between the Referring Agent and the Residential Team can occur in-person or by phone. 4. Program Exits: the Residential Team will notify the Central Addiction Intake Team of both planned & unplanned client exits. The Central Addiction Intake Clinicians will use this information for future waitlist management, and will notify the Referring Agent via PARIS, phone or . Contact Andrew Stone or Stacy Folk (Central Addiction Intake Clinicians) with any questions, comments or concerns: ANDREW: clients call: , staff call: STACY: clients call: , staff call: ALL S: CentralAddictionIntakeTeam@vch.ca

2 REFERRING TO: PACIFICA (co-ed Treatment Program) CENTRAL CITY LODGE (ARP) (STLR men only) Central Addiction Intake Referral for Residential Treatment & Stabilization Transitional Living Residences (STLRs*) NEW DAWN (STLR - women only) TOGETHER WE CAN (STLR men only) *also known as Support Recovery Forward completed assessments to Andrew Stone and/or Stacy Folk via fax: Please contact Andrew or Stacy with any questions or concerns: phone: or CentralAddictionIntakeTeam@vch.ca. CLIENT NAME: DOB (m/d/y) GENDER: MALE FEMALE TRANSGENDERED AGE CONTACT #(s) HM # CELL# ADDRESS: ( NFA) REASON FOR ASSESSMENT: REFERRING AGENT: SOCIAL INSURANCE # PERSONAL HEALTH # (MSP) ASSESSMENT START DATE ASSESSMENT END DATE PHONE EXT AGENCY/PROGRAM: SUBSTANCE USE ASSESSMENT: PRIMARY PROBLEM SUBSTANCE Alcohol PRIMARY ROUTE Oral, Nasal, Sublingual, Anal, Smoke, Inhale, Intravenous, Intramuscular Transbuccal LAST DATE OF USE # OF DAYS OF USE IN LAST 30 TYPICAL AMOUNT USED DAILY AGE AT FIRST USE CURRENT PATTERN OF USE CURRENT STAGE OF CHANGE Pre-contemplation Contemplation Preparation Action Maintenance Alcohol (Non-Beverage) Tobacco Cannabis Crack Cocaine Cocaine Heroin Opiates Benzodiazepines Crystal Meth Amphetamines Club Drugs Hallucinogens Inhalants Retail OTCs Other Rx Meds Other: Vancouver Coastal Health Residential Tx & STLR Referral - Pg 1/10

3 SUBSTANCE USE ASSESSMENT cont d: Client has shared needles with other users within the last 30 days: N/A YES: Primary drug(s) of choice: longest abstinence ever achieved: Current risk of relapse: NO YES: Other comments on client s substance use: OTHER PROBLEMATIC BEHAVIOURS: PRIMARY PROBLEM BEHAVIOUR DATE LAST ENGAGED # OF DAYS ENGAGED IN LAST 30 AVG # OF HOURS DAILY MAX # HOURS DAILY AGE AT FIRST EXPERIENCE CURRENT STAGE OF CHANGE Gambling Sex Electronics Pornography Other: Other: Primary problematic behaviour(s): longest abstinence ever achieved: Current risk of relapse: NO YES: Other comments on client s problematic behaviours: FAMILY HISTORY OF ADDICTIONS: Family hx of substance use: N/A YES - DETAILS: Family hx of other problematic behaviours: N/A YES - DETAILS: Other Comments: IMPACTS OF SUBSTANCE USE: (Please check all that apply) PHYSICAL MENTAL HEALTH SOCIAL Blackouts Disrupted Sleep Relationship Concerns Overdose Paranoia Financial Concerns DTs Depressed Mood Employment / Education Concerns Withdrawal Seizures Anxiety Drug Trade Involvement Weight GAIN LOSS Self-Harm Sex Trade Involvement Gastrointestinal Problems Harm to Others Other Criminal Activity Infections Other: Other: Vancouver Coastal Health Residential Tx & STLR Referral - Pg 2/10

4 TREATMENT & SUPPORTS: Services Accessed - Past & Current: Withdrawal Management: Social Supports: Individual Group Peer Supports Day Treatment Program(s) Residential Treatment Program(s) Details STLRs (Support Recovery) Specialized/Other Supports Other Supports: Other Supports: OPIATE MAINTENANCE THERAPY: Participation (# of times) Completion (# of times) Current Opiate Maintenance Therapy: N/A YES Methadone/Methadose Buprenorphine (Suboxone) Follow-up required? N/A YES Start Date: Current Dose: Carry Privileges: YES NO Current Therapy Past Opiate Maintenance: Therapy Participation (# of times) Highest Dose (mgs) Longest Treatment (months) Methadone/Methadose Suboxone Current Therapy CLIENT S SELF-IDENTIFIED TRIGGERS: FEELINGS THOUGHTS PHYSICAL Stress Negative Self Thinking Pain/Discomfort Pleasant Feelings (eg: happiness) Racing / Can t Concentrate Disordered Sleep Unpleasant Feelings Hallucinations: Sexual Inhibitions/Performance Boredom/Loneliness Delusions Isolations Shame/Guilt Other: Urges/Cravings Vancouver Coastal Health Residential Tx & STLR Referral - Pg 3/10

5 CLIENT S SELF-IDENTIFIED TRIGGERS cont d: SITUATIONS/ENVIRONMENT INTERACTIONS PRESSURES/STRESSORS Specific areas/locations Pleasant Social Family Unpleasant/Conflicted Sexual Relationship Other users Financial Enhanced Experience Other: Family Other Substance Use Other: Other: Other MENTAL HEALTH: Current Mental Health Issues: N/A YES (Clinician Observation of) Client s Presentation: Thought & Cognition: Mood/Affect: Other Observations: Other MH Details & Hx: Appearance: Behaviour: Energy/Concentration: Speech: Thought Form: Thought Content: Cognition: Depressed Elevated or Hypomanic Anxious Obsessions/Compulsions Calm/Lucid Other: Undiagnosed PTSD Suspected Other Undiagnosed Mental Health: Sleep: Eating/Drinking: Other: SUICIDALITY: Risk of Suicide: N/A YES Current Ideation: YES NO Previous Attempt(s): N/A YES #: Date of last attempt: Clinician Suspected Risk: YES NO Current Intent: YES NO Current Plan: YES NO Vancouver Coastal Health Residential Tx & STLR Referral - Pg 4/10

6 OTHER RISKS: Harming Others: N/A YES Self-Harm: N/A YES Harm/Violence by Others: N/A YES Current Child Safety Concerns: Previous Attempt(s): # & Method: N/A YES N/A YES #: Date of last attempt: FAMILY HISTORY OF MENTAL HEALTH: Family hx of mental health issues: N/A YES GENDER, SEXUALITY & RELATIONSHIPS: Gender: Client s Self-Identified Gender Client s Self-Identified Gender Issues: Sexual Orientation: Primary Self-Identified Orientation: Secondary Self-Identified Orientation: Client s Self-Identified Sexual Orientation Details/Unaddressed Issues Partners/Relationships: Safety Concerns: N/A YES Relationship Concern: N/A YES Other Comments: Family: Identified Issues: N/A YES Parenting: Currently parenting: N/A YES MCFD Involvement: N/A YES MCFD Social Worker Name & Contact Information: OTHER NEEDS ASSESSMENT: Living Situation: Current Housing: YES NO NFA Other: Cultural Experiences: Identified Issues: N/A YES Other: Vancouver Coastal Health Residential Tx & STLR Referral - Pg 5/10

7 OTHER NEEDS ASSESSMENT cont d: Spirituality: Identified Issues: N/A YES Other: Negative Life Events/Trauma: Identified Issues Primary: N/A YES Other: Financial/Income Issues: Identified Issues Primary: N/A YES Other: Vocation/Education: Identified Issues Primary: N/A YES Other: Current Legal Involvement: Identified Issues Primary: N/A YES Other: MCFD INVOLVEMENT Needs Assessment - Other Comments: FUNCTIONAL ISSUES: (Nurse/Doctor to Complete) ADLs Eating/Nutrition Mobility/Ambulation IADLs Hearing Vision Breathing Dental Communication Literacy Cognitive Impairment Suspected FASD Special Aids Used or Required: N/A YES CURRENT PHYSICAL HEALTH: Pregnancy: Currently Pregnant: N/A YES Due Date: Pregnant in the last 2 years: YES NO Prenatal Care Provider Contact Info: Pregnancy Issues: N/A YES Other Vancouver Coastal Health Residential Tx & STLR Referral - Pg 6/10

8 COMMUNICABLE DISEASES: HIV+ HCV TB STIs Other: Current TB Test Completed: YES NO Comments/ Doctor/Nurse Signature: Doctor/Nurse (Print Name): Address: Client Signature: Date: Phone: Date: CURRENT MEDICATIONS: MEDICATION ROUTE DOSE FREQUENCY START DATE END DATE Prescribing Physician: Clinic/Program: Phone: xt: Client s Medication Issues: N/A YES Other: Other Comments/ CURRENT MENTAL HEALTH DIAGNOSES: DATE DIAGNOSIS TYPE DIAGNOSIS STATE AWARE? Other Diagnosis Comments/ UNDIAGNOSED/ACTIVE DISORDERED EATING Vancouver Coastal Health Residential Tx & STLR Referral - Pg 7/10

9 CURRENT ALLERGIES: ALLERGEN REACTION DETAILS Other Comments/ SYMPTOMS REVIEW IDENTIFIED ISSUES: Head, Eyes, Ears, Nose & Throat: Hearing Impairment Difficulty Chewing/Swallowing Visual Impairment Comments/ Respiratory: Laboured/ SOB / Impaired Crackles / Wheezes Cough Comments/ Cardiovascular: Irregular Pulse Tachycardia Bradycardia Peripheral Edema Other: Other: Comments/ Neurological: Unsteady Dizziness/Syncope Numbness/Tingling Drug/ETOH Affected Confusion Other: Hx of Seizures Date of Last Seizure: Other: Comments/ Gastro-Intestinal: Nauseau/Vomiting Abdominal Pain Diarrhea Constipation Weight Change Other: Date of Last BM: Other: Other: Comments/ Vancouver Coastal Health Residential Tx & STLR Referral - Pg 8/10

10 SYMPTOMS REVIEW IDENTIFIED ISSUES cont d: GU/Gynecological: Incontinence Birth Control/Contraception Peri-Menopause/Menopausal Date of last Period: Comments/ Endocrine: Identified Issues: N/A YES Comments/ Musculoskeletal/Skin: Pregnancy Test Completed: YES NO N/A Other: Cellulitis Abscess Itching/Irritation Trauma Other: Other: Comments/ General or Other Identified Issues: Comments/ CLIENT S PERSPECTIVE & STRENGTHS: ACTIONS THOUGHTS FEELINGS has past periods of stability understands health issues hopeful willing to try new options finds beauty/humour in world joyful able to voice thoughts/feelings has realistic goals grateful uses healthy self-reward uses positive self-talk positive Other: Other: Other Other: Other: Other PERSONAL SUPPORTS PRACTICES effective money management family creative healthy nutrition management community involvement cultural/spiritual good self-care cultural / spiritual connection meditation/relaxation good hygiene self-help groups community involvement good sleep routines sponsor/mentor regular exercise/physical activity Vancouver Coastal Health Residential Tx & STLR Referral - Pg 9/10

11 CLIENT S PERSPECTIVES & STRENGTHS cont d: MOTIVATORS TO CHANGE financial healthier relationships living conditions/housing legal better physical health/wellness employment/education family/children better mental health/wellness Other: Current Symptom Management/Coping Strategies: Comments/ Client Comment/Perspective: Comments/ Referring Agent Signature: Doctor/Nurse (Print Name): Address: Client Signature: Date: Phone: Date: Vancouver Coastal Health Residential Tx & STLR Referral - Pg 10/10

12 Vancouver Community Addiction Services CLIENT CONSENT FOR THE RELEASE/EXCHANGE OF INFORMATION PACIFICA (co-ed Treatment Program) CENTRAL CITY LODGE (ARP) (STLR men only) NEW DAWN (STLR - women only) TOGETHER WE CAN (STLR men only) CLIENT AUTHORIZATION: My signature authorizes the release and/or exchange of information between the VCH Central Intake Clinicians(s), staff at the above-noted facility, and the service providers noted below. This authorization is valid for preadmission and collaboration of care purposes, and for the duration of my stay at the above-noted facility, and at no other time. Client Signature. REFERRING AGENT IDENTIFICATION/VERIFICATION: Print Name Referring Agent Signature Date Agency / Organization Date SERVICE PROVIDER NAME AGENCY / ORGANIZATION Addictions Counsellor Other Counsellor Physician (GP) Addictions Physician Psychiatrist Clinical Therapist Mental Health Worker Housing Worker Other Support Worker Probation/Parole Officer Lawyer MCFD Social Worker Victims Services Worker EAP Claims Representative Insurance Representative Other Service Provider Other Service Provider TELEPHONE # (include extensions) FAX # or

13 Vancouver Community Addiction Services PHARMACY INTAKE MEDICATION FORM Please have your physician complete this form to indicate medications you will require while in residence at: PACIFICA (co-ed Treatment Program) CENTRAL CITY LODGE (ARP) (STLR men only) NEW DAWN (STLR - women only) TOGETHER WE CAN (STLR men only) PATIENT INFORMATION: Name: Telephone #: (If Applicable) Extended Health Insurance: Insurance Provider: All Relevant Plan ID Numbers: Plan Name: PHN: BIRTH DATE: CLIENT AUTHORIZATION: My signature authorizes the release and exchange of information between the VCH Central Intake Clinicians(s), staff at the above-noted facility, my prescribing physician, and the dispensing pharmacy. This authorization is valid for pre-admission purposes, and the duration of my stay at the above-noted facility, and at no other time. Client Signature Date TO BE COMPLETED BY PHYSICIAN: Thank you for indicating below the prescribed medication(s) you anticipate being continued/provided for the above-named patient while s/he is in residence at the above-noted facility. When applicable, please note administration time(s) and whether the prescription is PRN. Unless otherwise noted, the medication(s) noted below will be provided for three months (the average duration of treatment). The medication(s) will be dispensed weekly to the above-noted facility for administration to the patient under supervision of facility staff. RE: Methadone/Methadose or Suboxone - Central City Lodge & Pacifica require delivery to their sites; for these centres, please also: supply a duplicate prescription indicating to be witnessed by treatment /support recovery centre staff specify that deliver to the appropriate centre (Central City Lodge or Pacifica) is required MEDICATION DOSE ADMINISTRATION TIME(S) MD SIGNATURE PLEASE FAX THIS FORM WITH THE CLIENT S REFERRAL PACKAGE / MEDICAL ASSESSMENT TO THE CENTRAL INTAKE TEAM: FAX: ATTN: ANDREW STONE AND/OR STACY FOLK. FACILITY PHARMACY INFO IS BELOW FOR YOUR REFERENCE: Pacifica: Kerrisdale Pharmacy phone: fax: West Boulevard (at West 40 th Avenue) Vancouver, BC V6M 3W6 New Dawn: Safeway Pharmacy (Contact: Christine) phone: xt 4 fax: West 25 th Avenue Vancouver, BC V5Z 2EZ Central City Lodge: Together We Can: DATE Remedy s Pharmacy phone: fax: East Hastings Street Vancouver, BC V6A 1R5 Safeway Pharmacy (Contact: Simon) phone: fax: Kingsway Vancouver, BC V5R 5L4

14 Ministry of Health Patient Consent for Treatment Providers to Access PharmaNet Information The Province of British Columbia has established the provincial computerized pharmacy network and database known as PharmaNet pursuant to Section 37 of the Pharmacists, Pharmacy Operations and Drug Scheduling Act, R.S.B.C. 1996, c REGARDING: [Patient Name, Please Print] DOB: PHN#: I,, [Patient Name, Please Print], authorize access to my personal health information contained within Pharmanet by medical practitioners, pharmacists, and other authorized persons for the purpose of providing therapeutic treatment or care to me in [Facility Name, Please Print] ( the Facility ). If I have a keyword on my medication profile, I will provide the keyword to enable the Facility s access to my PharmaNet information as required. When I am no longer receiving care or treatment from the Facility, the keyword that I have provided will be removed from all records relating to me. I understand that if I am not able, for any reason, to provide my keyword, and a medical practitioner has reasonable grounds to believe that safe and effective care and treatment cannot be provided without accessing my medication profile, he/she will do so by contacting the PharmaNet Help Desk to have the keyword removed from my profile. I understand that this consent will expire when I am no longer receiving care or treatment from the Facility. If I wish to withdraw this consent prior to that time, I understand that the withdrawal must be in writing and delivered to the Facility directly. Signed at, British Columbia, this day of, 20. Patient/Guardian Signature Witness Signature Witness Name, Please Print

15 Vancouver Community Addiction Services MSDSI Funding Verification Request Form TO: ATTN: RE: RETURN TO: Ministry of Social Development & Social Innovation Kiwassa Office VCH Regional Virtual Team SDSI Admin Team FAX: PER DIEM CONFIRMATION FOR: Referring Agent: VCH Addictions Intake Team Andrew Stone & Stacy Folk Fax back to: Fax back to: Client Name DOB: (PHN # SIN # ) has been referred for admission to a qualifying residential addictions program. Prior to admission, the facility requires confirmation that the client s per diem costs (less any non-exempt income) will be paid by MSD while in receipt of, and eligible for, income assistance. Authorization I,, authorize the Ministry of Social Development to confirm my eligibility for funding, and to release any related information to the above named staff. Client Signature Date MINISTRY OF SOCIAL DEVELOPMENT - COMPLETE & FAX TO THE FACILITY NOTED ABOVE CLIENT GA #: CASE #: APPLICATION SR #: Client has an open & active MSD file: YES NO Client is ELIGIBLE or INELIGIBLE for funding. (check only one box) Client s per diem will be paid by MSD as per current eligibility, less any non-exempt income: (If applicable) Less any non-exempt income (monthly amount divided by 30 days) Per Diem Rate: $ Non-exempt income from CPP or OTHER SOURCE: (If applicable) Nutritional Subsidy: $40._00_00 per month. $40._00_00 MSD Per Diem for Client = $40. 00_ Completed by: Print Name Only Signature: Date:

16 Vancouver Community Addiction Services Accommodation Fee Subsidy Instructions for Referral Agents The application for an Accommodation Fee Subsidy (AFS) must be submitted by a Referral Agent (ie: the Counsellor or Social Worker who has screened/assessed the client to determine their best treatment option(s). AFS funds are approved for use only at facilities in receipt of provincial Health Authority funding (List Attached). Determining Eligibility eligible clients can access AFS funds to attend residential Treatment and/or Stabilization and Transitional Living Residences (formerly known as Support Recovery facilities). The funds are available to low-income clients who cannot afford full per-diem costs, who do not qualify for MSD Income Assistance, and who have no other financial assets or resources upon which to draw. eligibility for AFS funds is determined through an income / cash / assets assessment: if the client s total income / cash assets exceed $1600 per month, s/he is not eligible if the client s total income / cash assets exceed $1600 per month, and there are demonstrated cost-pressures that continue to indicate hardship (ie: shelter, utilities, medical costs, child support payments), exceptions may be possible. In these cases, additional supporting documentation regarding the specific cost-pressures must be submitted with the application. (NOTE: VCH Addiction Services strives to reduce personal financial barriers that lead to hardship in accessing residential treatment services; however, due to limited resources, it may not be possible to accommodate every request fpr exception.) clients must provide documentation verifying their current income / cash assets, and this documentation must be submitted with the AFS application Completing the Application use the revised application form (attached) AFS Application Form clients financial documentation must be attached and submitted with the application form, including Employment Insurance and/or Income Assistance application documentation and any applicable additional cost-pressures documentation). for eligible clients, determine the Accommodation Fee portion using the table below: Net Monthly Income / Fee Portion Cash Assets Client Subsidy Total Less than $1,100 $0 $40 $40 $1,101 to $1,350 $14 $26 $40 $1,351 to $1,600 $26 $14 $40 $1,600 + $40 $0 $40 if your client is being referred to more than one facility, enter all (to a maximum of 3) contact the facility or the Central Intake Team (as applicable) to determine availability and planned admission date(s) all approvals are for 30 days of funding at a time. A maximum of two additional requests for 30 days each can be made for each client. FAX AFS APPLICATION & ALL ADDITIONAL DOCUMENTATION TO , ATTN: PAT SMITH Subsidy Approval applications will not be back-dated if the client is already in the facility total subsidy is limited to a maximum of 90 days per client per fiscal year (1 April 31 March), for any combination of stays in any VCH-funded facility (ie: 30 days of Treatment + a maximum of $60 days of funds for residence in a STLR), with no exceptions upon approval of funds, Pat will assign the billing reference number & forward it to the Referring Agent & the facility(ies) the client will attend approvals for AFS funds will expire if clients are not admitted within 60 days of the AFS application date ANY CONCERNS OR INQUIRIES RE: VCH AFS FUNDING AND/OR APPLICATIONS CAN BE DIRECTED TO: Pat Smith: / patricia.smith@vch.ca

17 Vancouver Community Addiction Services Accommodation Fee Subsidy Approved Residential Services Reviewed October 2013 Only facilities in receipt of provincial Health Authority funding are eligible for referral for the Accommodation Fee Subsidy (AFS). The following is a partial list other services in BC receiving Ministry of Health funding, are also eligible to receive AFS funds. Clients can be subsidized to a total maximum of 90 days per fiscal year (1 April 31 March), and this includes any combination of placements (ie: residential treatment and stabilization and transitional living residences combined). VANCOUVER COASTAL HEALTH FUNDED FACILITIES Pacifica Treatment Centre (co-ed Tx) Central City Lodge (STLR men only) New Dawn (STLR women only) Together We Can (STLR men only) OTHER AFS-ELIGIBLE FACILITIES 1755 East 11 th Avenue Vancouver, BC V5N 1Y9 415 West Pender Street Vancouver, BC V6B 1V2 Facility Address provided to clients upon their Admission Confirmation Head Office: 2831 Kingsway Vancouver, BC V5R 5H9 Heartwood Centre for Women 5 th Floor 4500 Oak Street (women-only tertiary Tx) Vancouver, BC V6H 3N1 Maple Ridge Treatment Centre Calligan Avenue (Tx men only) Maple Ridge, BC V2X 2E2 Kinghaven (STLR men only) King Road (RR #1) Abbotsford, BC V2T 6C2 Peardonville 825 Peardonville Road (Tx - women & their 3-5 y/o children) Abbotsford, BC V4X 2K3 Turning Point (STLR coed, NO MMT) 455 West 13 th Avenue Vancouver, BC V5Y 1W4 Turning Point (STLR men, NO MMT) Odlin Road Richmond, BC V6X 1E2 Charlford House (STLR women only) 6845 Kitchener Street Burnaby, BC V5E 2S8 Hannah House (STLR women only) c/o Inner Visions Maple Ridge, BC Inner Visions (STLR men only) 1937 Prairie Avenue Coquitlam, BC V3B 1V5 Kiwanis House / Sage Health Centre 101 Columbia Street (Tx coed) Kamloops, BC V2C 2S7 Last Door (STLR adult men only) 323 Eighth Street New Westminster, BC V3M 3R3 Liz s House / Ellendale (Tx women only) Ellendale Drive Surrey, BC V3R 0A3 Liz s House II nd Avenue Surrey, BC V3V 1H4 Path to Freedom (STLR men only) th Avenue Surrey, BC V3S 7N4 Phoenix D & A Centre A Avenue Surrey, BC V3V 1N1 Sea to Sky (STLR coed) PO Box nd Avenue Squamish, BC V8B 0A7 Valley House (STLR men only) c/o Kinghaven Abbotsford, BC Westminster House (STLR women only) 228 Seventh Street New Westminster, BC V3M 3K3 tel: fax: tel: fax: tel: fax: tel: fax: tel: fax: tel: fax: tel: ext 13 fax: tel: xt 0 fax: tel: fax: tel: fax: tel: fax: tel: fax: tel: fax: tel: fax: tel: fax: tel: fax: tel: fax: tel: fax: tel: fax: tel: fax: tel: tel: fax: NOTE: Wagner Hills & Paeztold Rehab Centre in the Fraser Health Region are not Health-funded facilities.

18 Vancouver Community Addiction Services Accommodation Fee Subsidy Application Reviewed March 2011 APPLICATION DATE / / BILLING REFERENCE # MONTH DAY YEAR CLIENT NAME NET MONTHLY INCOME $ SOURCE CASH ASSETS $ SOURCE BIRTHDATE MONTH DAY YEAR TOTAL $ NUMBER OF PERSONS DEPENDENT ON THIS INCOME (Including client) NOTE: MUST ATTACH PROOF OF INCOME & CASH RESOURCES ACCOMMODATION FEE PORTIONS + = $40 PER DAY CLIENT VCH ELIGIBLE FOR INCOME ASSISTANCE? APPLIED FOR IA? DATE APPLIED ELIGIBLE FOR EMPLOYMENT INSUR.? APPLIED FOR EI? DATE APPLIED NOTE: MUST ATTACH DOCUMENTATION FOR ABOVE REFERRING SERVICE (eg. CHC NAME) FAX NUMBER REFERRAL AGENT TEL NUMBER REFERRAL(S) TO RESIDENTIAL FACILITY(IES) If more than one referral, list all NOTE: only one placement will be funded PROJECTED ADMISSION DATE # DAYS FOR FEE NAME MONTH DAY YEAR SUBSIDY For Residential Treatment: confirm program length (Aurora: days, MRTC: days, Crossroads: 30, Kinghaven is 70, Peardonville House: 70, Pacifica: 60 days will be approved with max 30 day extension by request) For Stabilizing & Transitional Living Residences (aka: Support Recovery ): 60 days will be approved max 30 day extension by request SIGNATURES I certify that I have carefully reviewed my financial situation & the information provided is true to the best of my knowledge. I understand that the information provided will only be used to process my application for accommodation fee subsidy and will be protected under the Freedom of Information and Privacy Act. DATE CLIENT Signature REFERRAL AGENT Signature SUPERVISOR Signature FACILITIES MUST COMPLETE THIS SECTION & FAX TO MICHELLE MAYNARD-BEALL IMPORTANT: ADMISSION DATE MUST BE CONFIRMED OTHERWISE INVOICES WILL NOT BE PAID If client is approved for Income Assistance, MSD will pay the per diem. Complete the Departure / Subsidy End Date & Reason for Subsidy Termination If client leaves, complete the Departure / Subsidy End Date & Reason for Departure Any extra days over the number approved must be requested & approved. Complete the Request for Extension FACILITY NAME REQUEST EXTENSION TO DATE OF REQUEST ADMISSION DATE MONTH DAY YEAR MONTH DAY YEAR MONTH DAY YEAR APPROVED DEPARTURE / SUBSIDY END DATE MONTH DAY YEAR REASON FOR DEPARTURE / SUBSIDY END IA FUNDING EI FUNDING OTHER FUNDING COMPLETED OPTED OUT RELAPSE BEHAVIOUR UNSUITABLE OTHER