p HEARTWOOD CENTRE FOR WOMEN CLIENT REFERRAL PACKAGE
REFERRAL INFORMATION PACKAGE Heartwood, a residential treatment program, is a provincial tertiary 30 bed resource for women with substance dependence, mental health concerns (including trauma) and primary health and/or chronic disease issues. Program length: up to 90 days. Inclusion criteria! Current substance use/dependence! Client is aware of referral and willing and able to participate in treatment! BC females (including transgendered women) ages 19 and older Not everyone with substance dependence requires residential treatment. Generally women who will be accessing this program will have chronic substance use with other co-morbidities including mental health issues and physical health concerns. Community based treatment services have not been effective or perhaps unavailable for this group of women. They may likely have had many attempts at treatment across a wide range of services. The goal of the program is to provide a safe environment for women to establish a solid foundation of recovery, have all of their health concerns stabilized and a plan for ongoing supported recovery in their community following discharge. Program: Heartwood is a comprehensive gender responsive treatment program which addresses women s bio-psycho-social spiritual needs. An interdisciplinary team including nurses, physicians, psychiatrists, counselors (including an aboriginal counselor), social worker, recreational therapist, dietician, music therapist, art therapist and alternative practitioners collaborate with women to help them meet their treatment goals. The program is divided into two areas. The first is the S.T.A.R. program (stabilization, assessment and retreat). Women will be in this program area for one to two weeks. This program will assist the women to stabilize in their physical and mental health. Addiction medicine and nursing assessments are completed during this time. Psychiatric assessments will also be completed as required. Withdrawal management issues will be addressed and other treatments such as methadone, tobacco dependence treatments, primary health care, nutritional interventions, acupuncture as well as group work will be provided. The second program area is Treatment. During this phase women can expect to be involved in individual and group counseling (with the emphasis on group), alternative therapies and recreation therapies. Treatment approaches include but are not limited to cognitive behavioral therapy, motivational therapy, DBT, mindfulness based therapy, psycho-education, skill development, pharmacotherapy, and trauma informed practice, 12 step programs and peer support. Nov 2011 1
REFERRAL INFORMATION PACKAGE Care Planning Each woman will be assigned a care team. Throughout Treatment the referral liaison will be contacted to ensure continuity of care and treatment planning during the woman s stay at Heartwood. Transition Planning Transition plans will begin as soon as the women complete their stabilization. The social worker will work with women and their care team to determine a best fit for aftercare ensuring a continuum of treatment whenever possible. The social worker will liaise with the referral liaison in the home community and collaborate on transition planning throughout the women s treatment. A transition plan will be established in case of an early exit from the program in order to ensure safety for the women returning to her home community. In order to ensure a smooth transition it is recommended that the woman have a simple re-entry plan upon referral. A more comprehensive transition plan will be developed collaboratively throughout treatment with the woman, the social worker and the support system in her home community. Physical violence, drug dealing/sharing and/or recruitment of other women into gangs or the sex trade will result in discharge from the program.! Please complete the attached referral form.! Attach all collateral information that you believe would be useful for the woman s treatment.! Please also ensure that the woman has a current TB screening test and attach the results to the referral form.! Complete and attach the Transition Plan form and Participation Agreement with the woman. Thank you for referring your client to our program. If you have further questions please contact Terri-Lee Seeley RCSW, Program Coordinator at 604-875-2032. Nov 2011 2
CLIENT INFORMATION PACKAGE The Heartwood Centre for Women is a community of staff and residents. The overall Heartwood Team includes many professionals that are here to assist you in your recovery. You will have a care team who will help guide you through the treatment at Heartwood. The community is here to help and support you - we want you to succeed and will help you as much as possible. What we do The Program helps you to:! Identify your strengths and apply these to a long term recovery plan! Improve your emotional, physical, mental and spiritual well being! Understand the role drugs and alcohol have played in your life! Understand the role of mental wellness with substance use! Set realistic goals and learn how to live without depending on drugs and alcohol! Learn skills to improve the quality of your family and community relationships! Decrease your involvement with the law! Set realistic goals for education and / or employment! Help you to re-enter the community after treatment! Help with money management and housing applications The Program S.T.A.R. (Stabilization, Assessment and Retreat) The first one to two weeks of the program, you will meet with the nurse, physician, psychiatrist, counselor, social worker and other therapists. This is your care team and they will help you set goals for your treatment. The goals for this stage include managing withdrawal from substance use, identifying and treating medical and psychiatric issues, developing stable daily routines, learning to live in a community, developing healthy sleep and hygiene habits and learning to engage in structured programming. At day one of S.T.A.R. you will abstain from tobacco use and be treated with a variety of nicotine replacement therapies (as appropriate). You will be asked to begin to attend a smoking cessation group. Treatment The primary goal of Treatment is to introduce you to the various types of education and treatment that you will need to achieve a full recovery in your substance dependency and mental and physical health. In Treatment you will identify the strengths that you bring to your recovery. You will plan treatment with your care team and have many choices about the groups and activities that you participate in all based on your individual needs. You will be asked to attend regular groups and individual sessions according to your treatment plan Nov 2011 1
CLIENT INFORMATION PACKAGE IMPORTANT INFORMATION: There is a two-week retreat period upon admission whereby you will be asked not to communicate with outside family or supports. In the case of an emergency special consideration will be given through your primary counselor. All rooms are shared occupancy. Physical violence, drug dealing, sharing and/or recruitment of other women into gangs or the sex trade will result in discharge from the program. Family visits are on Sunday from 12 noon to 5 pm and one evening per week as scheduled in your care plan once retreat is complete. Heartwood is a tobacco free environment and abstinence from tobacco is required upon entry to the program (Nicotine Replacement Therapy is provided) Cell phones are not permitted for the duration of your stay. No personal lap tops or other devices will be allowed in the program. Mp3s and IPods are allowed outside of program hours. A Financial Aid Worker is assigned to the program. You will receive only your comfort allowance while in the program. If you are not on income assistance please bring a small sum of money for outings. You are discouraged from bringing larger sums of money to the program or valuables. (Heartwood is not responsible for valuables, personal lockers are in each room and locks are provided). Free laundry facilities are available, all food and snacks are provided. Passes (overnight and day) are scheduled with your care team as your treatment progresses and are not planned during the retreat time or the S.T.A.R. program. Heartwood and the hospital within which we are located is a scent free environment. Any perfumes or scented products will not be allowed in the building. Shampoo, soap, deodorant, toothpaste will be provided to you. WHAT YOU SHOULD BRING:! Clothing that is comfortable and clothing suitable for in-residence living and outings to the general community. A bathing suit.! Personal make up (scent free) Nov 2011 2
REFERRAL FORM Date of referral / / DD MM YYYY Inclusion Criteria! Current substance use/dependence! Client is aware of referral and willing and able to participate in treatment! BC females (including transgendered women) ages 19 and older Referral Information Health Authority: Contact Name Referring Practitioner (Primary Clinician) Address City Prov Postal Tel Email Physician Psychiatrist Financial Aid Worker Fax Tel Tel Tel Client Information Name D.O.B / / PHN Last First Initial dd/mm/yyyy Address City Prov Postal Tel Email Nov 2011 1
REFERRAL FORM Current Living Situation! Independent! Supportive housing! Partner/ Family! Homeless/ Inadequately Housed! Treatment center/ Hospital/ Detox (please specify) Substance Use Substance Amount Frequency Date of Last use Previous substance abuse treatment (brief history): Medical Conditions! TB Date of Last Test:! Chest x-ray! Mantoux skin test IMPORTANT: Results of TB test MUST be attached with this form! Pregnant: Due Date Other: Psychiatric Conditions Extended Leave! Yes! No Nov 2011 2
Current Medications! No medications HEARTWOOD CENTRE FOR WOMEN REFERRAL FORM Medication and dose Medication and dose Safety Concerns! Suicide attempts (please date most recent)! Overdoses (please date most recent)! Aggression/anger! Current domestic violence! Risk taking behaviors! Self harming behaviors! No current community supports Comments: Legal status if applicable ATTACH ALL RELEVANT DOCUMENTS TO REFERRAL FORM EG: ASSESSMENTS, DISCHARGE SUMMARIES, OTHER MEDICAL AND TREATMENT REPORTS, INCLUDING TB TEST RESULTS, TRANSITION PLAN, CONSENTS, SIGNED PARTICPATION AGREEMENT Nov 2011 3
TRANSITION PLAN The following plan will be put in place if I leave early from the Heartwood Centre for Women. I understand that as I continue treatment at Heartwood the social worker will assist me to develop a fuller transition plan to ensure my continued support and recovery when returning home. It is understood that if I leave the program on short notice my referral liaison and physician will be notified immediately. Name: D.O.B Community of Destination and address Name: Address: City: Prov: Postal: Housing: Independent (maintained during treatment) Family - Name: Tel: Shelter - Name: Tel: Income: Income assistance (Worker contact information) Name: Tel: Email: Key Contact for Transition Plan Name: Tel: Email: Signatures: Client: Key Contact: Date: Date: Nov 2011 1
PARTICIPATION AGREEMENT I have agreed to apply for treatment to the Heartwood Centre for Women and have reviewed the program services available. I understand that Heartwood is an abstinence-based program and I agree with the following. I will participate in the following activities upon arrival to Heartwood: Complete a physical examination with the program physician and nurses Meet with the psychiatrist if it is recommended Participate in a medication review Will participate in the required bed bug protocol: shower and wash clothing on admission Participate in an assessment and development of a treatment plan and follow this treatment plan Participate in group and individual counseling programs Will follow the retreat time (2 weeks) of the program and not have contact with outside people unless prearranged with my Care Team if there is an urgent need Work with the Heartwood social worker in order to plan a successful return home after treatment Follow program guidelines including no violence, no drugs and no recruitment of others into gangs or prostitution. Will not use any tobacco products during my treatment Will abstain from all drugs and alcohol except medication prescribed by the program physician during my treatment Will not use scents during my treatment Will not leave the program area unless it is planned with my Care Team Will restrict visits from family and supports to visiting hours unless otherwise authorized by my Care Team Will not bring cell phones or personal data devices Will keep all information about other program participants confidential Signature Signature Client Referral Agent Date Date Nov 2011 1
DIRECTIONS AND MAP HOW TO GET HERE Arriving By Car Enter the parking lot at 29 th and Heather St. Through the entrance gate you will see Women s Health Centre on the archway ahead of you. To your left is a circular parking lot where you can park for up to 15 minutes free of charge. Across from the parking lot is the main entrance to the Women s Health Centre. Heartwood Centre is located on the 5 th Floor. A staff member will meet you in the reception area. Arriving By Bus From Vancouver Bus Depot a taxi will cost approximately $20.00; tell the driver that you want to go to the 29 th and Heather St. entrance for the Women s Health Centre. City busses stop at 29 th and Oak but walking in with luggage is difficult. Public transportation information and routes can be found at http://tripplanning.translink.ca/. Arriving From Airport The easiest and quickest way to arrive here from Vancouver International Airport is by Taxi which will cost approximately $28.00. HEARTWOOD CENTRE Heather Street Entrance
MINISTRY OF SOCIAL DEVELOPMENT FUNDING VERIFICATION TO: Ministry of Social Development Office Attn Fax Tel FROM: HEARTWOOD Centre for Women Name Adrienne Horsfield Position Coordinator, Tertiary Access & Discharge Tel 604 730 7668 Fax 1-888-857-0371 Client Name SIN# The above named client 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 and non exempt income) will be paid by the MSD (Ministry of Social Development) while in receipt of, and eligible for, income assistance. Client Authorization I, authorize the Ministry of Social Development to confirm my eligibility for funding, and to release any related information to the above name staff. Client Signature Date MINISTRY OF SOCIAL DEVELOPMENT COMPLETE & FAX ABOVE Client has an open and active file YES NO Client has NOT applied for MSD within the last 30 days YES NO Client funding eligibility ELIGIBLE INELIGIBLE Client s per diem will be paid by the MSD as per current eligibility less a non exempt income from other. Sources: Per Diem Rate $40 If applicable Less any non exempt income (monthly amount divided by 30 days) $ Non exempt income from MSD Per Diem for client If applicable Nutritional Subsidy per month Completed by (print name) Signature MINISTRY OF OFFICE STAMP Date 7/17/2012