Native Courtworker and Counselling Association of British Columbia

Personal Information

Are you new to our program or are you returning: NewReturning If returning, do you want to continue with the same counselor: YesNo If same counselor, what is counselor’s name?

First Name:
Alias:
Middle Name:
Last Name:
Phone Number:
Cell/HomeFor MessagesVoicemail Street Address:
Homeless/Couch Surfing City:
Postal Code:
Email:
Facebook:
Gender: MaleFemaleTransgenderTwo-SpiritOther If Other, please specify:

Status: First Nations StatusFirst Nations Non-StatusNon-NativeInuitMetisSelf-Identified Indigenous If First Nations Status: Band: Status #: Emergency Contact Name:
Emergency Phone:

Referral Information

Referring Organization Name:
Have you been mandated to attend our program by? MCFD YesNo VACFSS YesNo Spirit of the Children YesNo

Have you been referred to attend our program by? Court YesNo Probation Officer YesNo Parole Officer YesNo If you answered ‘Yes’ to any of the above: What was the charge?

Reasons for attending our program

Alcohol MisuseDrug MisuseRelapse Prevention Problem GamblingInappropriate Sexual BehaviorsHarm ReductionStop Using CompletelyReferral to TreatmentAnger IssuesAnxietyDepressionSexual Abuse IssuesGrief and LossWitnessing ViolenceSocialization IssuesSpiritual ConfusionTrauma IssuesCo-dependency/Al-AnonAdult Children of Alcoholics Or Dysfunctional FamilyFamily ProblemsFind Stable HousingEmployment Problems Do you have any other reasons for attending our program?

Intake Background Questions

1. Marital Status:

Single (Never Married)Living Common LawDivorcedMarriedSeparatedOther (Incl. Widowed)

2. Dependents: (enter number)

#Children #Living with Client #Living with spouse/partner (Separated) #In Foster Care #Other Pregnant at Intake

3. Employment Status:

Full Time EmploymentPart Time EmploymentUnemployedRetiredStudentHomemakerSeasonalSocial AssistanceDisability

4. Education Level:

What is your highest grade you completed?
Grade Other Education: High School GradUndergraduateVocational/Trade SchoolGraduate DegreeG.E.D.Some College

5. Substance Misuse:

Which substance(s) do you use? AlcoholCannabisCocaine/crackHallucinogensBarbituratesAmphetamines/CrystalEcstasy (Other club drugs)HeroinIllicit MethadoneOther OpiatesBenzodiazepinesSpeedballTranquilizersAnti-DepressantsNon-Opiate Pain KillersAnti-psychoticsOver the counterInjection User

6. Do you misuse more than one substance on a regular basis?

YesNo

7. Are you challenged with:

FASDADHDOCD

8. Do you to prefer to have sessions?

In PersonBy Telephone

9. Are you open to a group setting?

YesNo

10. Have you been diagnosed with Schizophrenia, BPD, Anorexia, Bulimia, PTSD, BP, Clinical Depression?

SchizophreniaBPDAnorexiaBulimiaPTSDBPClinical Depression

Statement of Client Confidentiality & Consent for Release & Exchange of Information

Client Name:
Date of Birth:

The information you will give will be created with strict confidentiality according to the law of B.C Freedom of Information and Protection of Privacy Act.

The NCCBAC’s Indigenous Outpatient Addictions Counselling and Detox Support Programs may need to release certain information about individuals to another agency, especially for collaboration for referrals. lf so, only the agency and contact person in the table below will be contacted.

All information you supply is voluntary. You will not be refused service if you choose not to supply all information requested. However, you have a responsibility to be a part of your own evaluation process, and this begins by talking openly and honestly with the NCCABC program personnel .The outpatient staff work as a team therefore we do consult with each other about clients.

The NCCABC’s Indigenous Outpatient Addictions Counselling and Detox Support Programs will provide reports to the funder Vancouver Coastal Health’s Aboriginal Health. The of the manager of the programs will request your written permission to utilize your program testimonial as a submission for funding purposes only.

Please discuss any questions you have concerning confidentiality with A & D staff. We can further explain your rights regarding the information you give to the program, if necessary.

I, ,

understand that all information gathered by NCCABC programs is considered confidential and will only be shared outside the NCCABC’s program, if I have given my written permission.

I also understand that is some situations information about me may be disclosed because it is our policy or is legally required. Information could be released without written permission in the following circumstances:

– Communication with health care professionals
– Communication with a Treatment Center
– Complying with a subpoena
– Responding to a threat of harm to self or others
– Reporting of suspected child abuse
– Responding to a medical emergency

If information is shared, not related to the above situations, please list any restrictions which may apply:

Additional Notes:

I hereby authorize the following agencies/people to be contacted for the purpose of releasing information to assist in my service needs:

The Native Courtworker & Counselling Association of British Columbia
NCCABC Personnel | Phone: 604-628-1143

Other Persons/Agencies (optional):
Client Initials: Date:

This agreement is valid for one year from where it is initialed and dated above:

I read and accepted the terms and policies for Confidentiality & Consent for Release form above.

Date: Witness Name:

Intake Form – Vancouver