T. Family Healing Program Referral Form Template

T. FAMILY HEALING PROGRAM REFERRAL FORM TEMPLATE

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of Household):

CASE NUMBER:

REFERRAL AGENCY (Referral Worker must fill in all sections)

Referral Worker:

Referral Agency:

Address:

Postal Code: Email:

Phone Number: Fax Number:

Requested Intake Date:

Any recommendations by Referral Worker:

Has the family accessed other organizations for help, support or healing (i.e., Treatment facility, shelter, community human services, therapy, etc.) £ Yes £ No

If yes, please specify what organization, when and why:

Organization:

When:

Why:

Additional detail:

Please indicate if the program or service has been completed. £ Yes £ No

If no, please explain:

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

GENERAL INFORMATION - FATHER

Last Name: First Name:

Date of Birth: Social Insurance Number:

Health Number: Telephone No:

Street Address:

Mailing Address:

Email:

Status Indian: £ Yes £ No Living on Reserve: £ Yes £ No

If yes, how long?

Band Name: Band Number:

Spiritual Beliefs: £Traditional £Roman Catholic £Anglican £Pentecostal £Other

Language(s) spoken by client: £English £Cree £Ojibway £Other

Language(s) client reads: £English £Cree £Ojibway £Other

Language(s) client writes: £English £Cree £Ojibway £Other

GENERAL INFORMATION – MOTHER

Last Name: First Name:

Date of Birth: Social Insurance Number:

Health Number: Telephone No:

Street Address:

Mailing Address:

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

Email:

Status Indian: £ Yes £ No Living on Reserve: £ Yes £ No

If yes, how long?

Band Name: Band Number:

Spiritual Beliefs: £Traditional £Roman Catholic £Anglican £Pentecostal £Other

Language(s) spoken by client: £English £Cree £Ojibway £Other

Language(s) client reads: £English £Cree £Ojibway £Other

Language(s) client writes: £English £Cree £Ojibway £Other

FAMILY INFORMATION

A) Number of family members wishing to attend the Lodge:

B) List all members:

NAME / GENDER (Sex) / DATE OF BIRTH / AGE

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

C) Does the family require a crib or bedrail, etc:

D) Does family have any mobility aids, i.e., wheelchair, e

E) Does family require a special diet?

If yes, please specify:

F) Please provide list of any medical needs your family will need:

FAMILY STRENGTHS (Check all that apply)

Willing to change / Community Supports / Access resources
Humour / Close knit / Read information
Show affection / Spiritual / Open to education
Stable / Positive outlook / Resilient
Rely on each other / Supportive friends / Involved in community
Prayer / Fishing
Meditation / Berry picking
Hunting / Camping
Trapping / Cutting wood

FAMILY SUPPORTS

Name / Relationship / Telephone Number

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

MEDICAL INFORMATION - FATHER

Doctor/Nurse:

Address:

Phone: ( ) Fax: ( )

EMERGENCY CONTACT - FATHER

Next of Kin: Relationship:

Address:

Phone: ( )

MEDICAL CONDITIONS – FATHER

Diabetes / £ Yes £ No
Seizure Disorders / £ Yes £ No
Chronic Respiratory conditions
(asthma, COPD, etc.) / £ Yes £ No
High blood pressure / £ Yes £ No
Allergies / £ Yes £ No List:
Eppie pen available / £ Yes £ No
Other, please list:

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

MEDICATIONS - FATHER

It is very important to bring a six week supply available.

Please list all medications that the FATHER will bring into the Lodge:

NAME / MEDICATION / DOSAGE / PURPOSE

COMMUNICABLE DISEASES – FATHER

Scabies / £ Yes £ No
Lice / £ Yes £ No
Other infestation / £ Yes £ No List:
Ringworm or fungal infection / £ Yes £ No
Measles / £ Yes £ No
Mumps / £ Yes £ No
Pertusis / £ Yes £ No
Bronchiolitis / £ Yes £ No
Gastro intern / £ Yes £ No
Other communicable disease / £ Yes £ No

*No person will be accepted until treatment has been completed or the contagious period is finished.

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

SPECIAL NEEDS – FATHER

Does the client need any special, physical or psychological needs or disabilities?

£ Yes £ No

If yes, please describe:

Are any of these issues affecting this FATHER now?

Suicidal behavior / £ Yes £ No
Family loss (death, separation, divorce) / £ Yes £ No
Spousal/Child loss / £ Yes £ No
Depression/sadness / £ Yes £ No
Abuse (sexual/physical) / £ Yes £ No
Family violence / £ Yes £ No
Anger / £ Yes £ No
Legal issues / £ Yes £ No
Gambling addiction / £ Yes £ No
Probation/parole / £ Yes £ No
Sex addiction / £ Yes £ No
Drug/alcohol abuse / £ Yes £ No
Solvent abuse / £ Yes £ No
Unsolved/resolved childhood / £ Yes £ No
Lack of parenting skills / £ Yes £ No
Lack of cultural knowledge / £ Yes £ No
Lack of communication skills / £ Yes £ No
Lack of life skills / £ Yes £ No
Relationship issues / £ Yes £ No
Residential School Survivor / £ Yes £ No
Secondary Resident School
(Parents attended residential school) / £ Yes £ No

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

SUBSTANCE ABUSE HISTORY – FATHER

Alcohol / £ Yes £ No
Drugs / £ Yes £ No
Has Father ever attended
Alcohol/drug treatment before / £ Yes £ No
Where:
When:
How long:

What are the main issues FATHER hopes to address while in treatment?

Treatment involves a Traditional-based family healing program. What ceremonies have you participated in the past?

What ceremonies are you hoping to participate in as part of your healing, i.e., Sweat lodge, ceremonies, smudging, etc?

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

HEALTH QUESTIONNAIRE - FATHER

Have you ever had heart diseases/heart attacks / £ Yes £ No
Does any family have heart disease/heart attacks / £ Yes £ No
Do you have a history of high blood pressure / £ Yes £ No
Do you have diabetes? / £ Yes £ No Type:
Does anyone in your family have diabetes / £ Yes £ No Type:
Do you have high cholesterol / £ Yes £ No
Do you have trouble sleeping / £ Yes £ No
Do you experience any headaches / £ Yes £ No
Do you have panic attacks / £ Yes £ No
Are you taking anti-depressant medication / £ Yes £ No
Are you currently under the care of a doctor / £ Yes £ No
Are you currently taking any prescribed medication / £ Yes £ No
Do you have any drug or food allergies / £ Yes £ No
Have you ever been treated or currently suffered from any of the following:
Cancer / £ Yes £ No
Nervous or mental disorder / £ Yes £ No
Sexually transmitted disease (STD) / £ Yes £ No
Depression / £ Yes £ No
Epilepsy / £ Yes £ No
Other, please explain: / £ Yes £ No

I have completed this form accurately to the best of my knowledge and ability.

Father’s Signature: Date:

Referral Worker’s Signature: Date:

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

MEDICAL INFORMATION – MOTHER

Doctor/Nurse:

Address:

Phone: ( ) Fax: ( )

EMERGENCY CONTACT - MOTHER

Next of Kin: Relationship:

Address:

Phone: ( )

MEDICAL CONDITIONS – MOTHER

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

MEDICATIONS - MOTHER

It is very important to bring a six week supply available.

Please list all medications that the MOTHER will bring into the Lodge:

NAME / MEDICATION / DOSAGE / PURPOSE

COMMUNICABLE DISEASES - MOTHER

*No person will be accepted until treatment has been completed or the contagious period is finished.

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

SPECIAL NEEDS – MOTHER

Does the client need any special, physical or psychological needs or disabilities?

£ Yes £ No

If yes, please describe:

Are any of these issues affecting this MOTHER now?

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

SUBSTANCE ABUSE HISTORY – MOTHER

Alcohol / £ Yes £ No
Drugs / £ Yes £ No
Has Father ever attended
Alcohol/drug treatment before / £ Yes £ No
Where:
When:
How long:

What are the main issues MOTHER hopes to address while in treatment?

Treatment involves a Traditional-based family healing program. What ceremonies have you participated in the past?

What ceremonies are you hoping to participate in as part of your healing, i.e., Sweat lodge, ceremonies, smudging, etc?

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

HEALTH QUESTIONNAIRE - MOTHER

I have completed this form accurately to the best of my knowledge and ability.

Mother’s Signature: Date:

Referral Worker’s Signature: Date:

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

CHILD/YOUTH HEALTH QUESTIONNAIRE

NOTE: THIS FORM TO BE COMPLETED FOR EACH CHILD/YOUTH

Child’s Last name: Child’s First Name:

Date of birth: Health Card number:

Does child have any health problems or concerns / £ Yes £ No
If yes, please explain:
Does child have a learning impairment / £ Yes £ No
If yes, please explain:
Has child been sick in the last two weeks: / £ Yes £ No
If yes, please indicate the illness:
Is child taking any prescription medication / £ Yes £ No
If yes, indicate reason, dosage:
Does child have any food, drug or material allergies / £ Yes £ No
If yes, please list:
Does child have trouble sleeping at night / £ Yes £ No
Does child nap during the day / £ Yes £ No
Time:
What helps child go down for a nap?
Does child have any disabilities? / £ Yes £ No
If yes, please indicate type:
Do you have any further comments/concerns:

FAMILY HEALING PROGRAM REFERRAL FORM

CLIENT NAME(S) (Head of household):

CASE NUMBER:

Child’s Last name: Child’s First Name:

Are any of these issues affecting this child/youth now?

FAMILY HEALING PROGRAM REFERRAL FORM