Sancta Maria House Admission Requirement Overview:

• Women 19 years of age or more. • A Program for women who have a substance abuse/ addiction or another

life changing addiction. • You must be at least 5 days clean and sober, No Methadone clients

accepted. • For women coming from Detox it is advisable that they come straight to

Sancta Maria House. • TB test either skin test or X-Ray and Admission Medical Admission Forms

to be completed and faxed to Sancta Maria prior to Intake Date. • Must have prescription script or medications for at least one month. • Women may request an interview at Sancta Maria House prior to

admission if so desired. • Women must be emotionally, physically and psychologically able to

participate in all aspects of our program. • Three month minimum commitment with open ended stay at Sancta Maria

House. • Sancta Maria House is a Stage One Healing and Recovery Home, women

are not permitted free access to community unless escorted by staff. • This is a Christian, 12 Step Program focused on spiritual, emotional,

psychological and physical journey in healing, self discovery, • Fees: $720.00 per month, Income Assistance, Disability or Self Pay • For Information call: 604 731-5550 Intakes: Monday to Friday 10-2 PM • Potentially addictive medications such as opiates, benzodiazepines and

barbiturates are not allowed. • Women with paranoid thoughts and other fixed delusions, auditory, visual,

or kinesthetic hallucinations, suicidal ideation or other thought disturbances which seem out of the person's control and not accessible to efforts to change indicate that Sancta Maria House would not be a suitable location to meet this persons particular needs.

Health Care card, SIN Card

Passport, or photo ID and birth certificate

Small amount of Toiletries and make up.

Stamps, envelopes, pens and paper (Email or

Internet access in not provided).

Weather-appropriate clothing and recreation

wear (i.e.; rain wear, good sneakers).

Sleepwear slippers, t-shirt, pajamas, housecoat,

sweat pants. Some smart casual for outings and Church. 1 suitcase only

Medications prescribed by physician.

Please do not bring any of these items listed below to Sancta Maria House: Items with an asterick will be discarded upon admission.

Alcohol.*

Books/Magazines of any kind.

Cameras.

Candles.

Cards and games.

Cellular telephones or pagers.

Cheque books and cheques.

Cigars that are alcohol flavoured.

Clothing that depicts alcohol, drugs, sex,

violence and gambling paraphernalia or casinos.

Clothing which is ripped, torn or very dirty.

Computers/electronic devices.

Drug paraphernalia.*

Food or drinks brought in from outside Cedars.*

Gambling paraphernalia.*

Gum.

Hair dye

Hair spray (aerosol is okay).

Keys.

Knives.

Light bulbs.

Lottery or scratch tickets (will be mailed home

to family).

Matches.

Medications (unless prescribed) and over-the-

counter medications.

Medication information printouts (unless given

to you by our physician).

Mood altering chemicals.*

Nail polish and remover.

Perfume, cologne, after-shave, strong perfumed

lotions and bath products.

Pictures/photo’s that depict alcohol/drug

usage, gambling, violence or sex.

Purses.

Sexually explicit clothing.

Sheets

Stuffed toys.

Televisions, radios, stereos, clock radios, i-

Pods, mp3 players, etc.

Towels. Wallets.

Weapons.

Zippos, lighter fluid or butane

ALSO, please be advised that any open packages of tobacco or cigarettes brought into

treatment will be discarded.

Note: All clothing will be searched upon admission.

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SANCTA MARIA HOUSE

PRE-ADMISSION INFORMATION

Resident Name: _________________________________Date / Time: _____________________

Date of Birth: ____________________________ Phone: ___________________ PHN:________________ SIN Number:______________________Address:__________________________________________________ Contact Person in case of Emergency: ___________________________________________________________ Address: ______________________________________________________________________ Relationship: ______________________________ Phone: ______________________________ What is your drug of choice? __________________________________________________________________ When did you last use your drug of choice? ______________________________________________________ When did you last use any other drugs or alcohol? _________________________________________________ What did you use? __________________________________________________________________________ Do you need Detox? Yes___ No___ Are You in Detox at the Present Time: __Yes_____No How many days did you use during the last month you were not in a facility? ___________________________ Have you ever been to a treatment center before? ___ Yes ___ No If Yes when, where and how long? _____________________________________________________________

__________________________________________________________________________________________

Describe your usual withdrawal symptoms_______________________________________________________ __________________________________________________________________________________________

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PRE-ADMISSION INFORMATION:

Do you or have you experienced seizures during withdrawal now or at any other time? Yes ___ No ___ Explain: _____________________________________________________________________ __________________________________________________________________________________________ Have you ever attempted suicide? Yes ___ No ___ When was the last incident? ___________________________________________________________________ Do you have suicidal thoughts? Yes ___ No ___ how often? _________________________________________

Have you been involved in prostitution? Yes ___ No ___ Length of time involved? _______________________

Have you ever been assaulted by your partner? Yes ___ No ___ When was the last incident? __________________________________________________________________________________________ Have you ever been charged or convicted of any crime (e.g. assault, breaking and entering, impaired driving, etc.)? Yes ___ No ___ If yes, when were you charged? _______________ Total time served? ___________ Please give details: __________________________________________________________________________________________ __________________________________________________________________________________________ Do you have charges pending or outstanding court cases? _____ Yes _____No: If yes, please give Dates and Details: Dates______________________________________________________ Details of Court Case ________________________________________________________________________ ______________________________Lawyer’s Name:__________________ Phone #________________ Do you have supportive friends or family who do not use drugs? ___ Friends ___ Family Do you have any psychiatric or medical conditions that need to be treated? ___ Yes ___No If Yes: Please Speci

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PRE-ADMISSION INFORMATION:

Do you currently have a reliable source of income or financial support? ___Yes ___No

If Yes what is it? ___________________________________________________________________________

Sancta Maria House Program Cost: $ 720.00 per month.

Income Assistance_______Disability_______Employment Insurance________ Self Pay_______

Please Indicate Choice of Payment:

Are you taking any prescription medication? ___Yes ___No

If yes please List: ______________________

__________________________________________________________________________________________

Residents must have a Pre-Admission Medical, TB test within the last 6 months or a chest X-ray.

Residents must have a severe addiction to drugs and/or alcohol which requires a residential facility.

Residents must be female and at least 19 years of age or older.

Residents must be drug and alcohol free for five days; this includes any prescription drugs that are considered

mood altering i.e. Tylenol 3’s, Adivan, etc.

All residents must be physically, psychologically and emotionally capable of taking part in all aspects of the

program including one-to-one and group counseling.

Residents must have no outstanding warrants or court dates that will conflict with their healing program.

Residents must plan on completing a minimum of three months treatment upon intake.

Residents must be open and willing to take part in the program and willing to explore their life, past issues,

addiction, spirituality and recovery issues.

____

There will be a 14 day stabilization period for residents of Sancta Maria in which they cannot leave the property

unless previously arranged and accompanied by a staff, a screened volunteer, or a senior resident.

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PRE-ADMISSION MEDICAL EVALUATION

To be completed by a Physician

Date: _____________ Phone No.:____________________________________ Client’s Name: _____________________________________________________________

CLIENT INFORMATION RELEASE:

To be signed by applicant

I hereby permit Sancta Maria House to release medical information to my physician. ________________________ __________________ Client’s Signature Date

PHYSICIANS PLEASE NOTE

Clients can not participate in the Sancta Maria House program if they are under the influence of mood

altering drugs.

The above client is to be medically assessed as a potential participant in our residential healing program. Our program is designed to interrupt the destructive cycle of addiction to drugs and alcohol that has negatively affected the lives of our client population. Our clients must be physically, emotionally, and mentally capable of participating in a program of intense one-to-one and group counseling. To assist Sancta Maria House in assessing this client’s suitability for treatment, please give detailed information to the following. Name of Physician: __________________________________________ Telephone Number: __________________________________________

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PRE-ADMISSION MEDICAL EVALUATION

Fax Number: ________________________________________________ Mailing Address: _____________________________________________ Client Information: Height: _______cm Weight: ______kg Date of last Chest X-Ray and/or Mantoux Test and Results (if over one year, please refer for TB Test or Chest X-Ray): __________________________ Allergies: _____________________________________________________________________

Significant Current Medical Conditions: _________________________________________________________ __________________________________________________________________________________________ Psychiatric Conditions and History: __________________________________________________________________________________________

History of Suicidal Ideation, Attempts, Slashing:

Pyschosis:_________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Current Medications: Date Prescribed: Prescribed By: (Include OTC and PRN meds) _________________________ __________________ ____________________________

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PRE-ADMISSION MEDICAL EVALUATION

________________________ __________________ ____________________________ _________________________ __________________ ____________________________ _________________________ __________________ ____________________________ Has there been any change in medication in the last 30 days? Please give details: ________________________

If you are aware of any special problems, physical or psychological, that should be taken into account while the client is in Sancta Maria, please indicate and give details (i.e. extreme anxiety, suicidal tendencies, depression,

etc.).

Do you consider the client physically and psychologically fit/able to attend the Sancta Maria Program?

____________________________ ________________________ Physician’s Signature Date Please remind your patient Sancta Maria requires clients to be free from the affects of mood altering drugs,

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PRE-ADMISSION MEDICAL EVALUATION

including alcohol and prescription drugs) for a minimum of 5 days previous to intake. Withdrawal from these drugs should be done in the safest possible manner for your patient. Clients benefit most from our treatment program when a period of abstinence has been achieved. Please call Sancta Maria @ (604) 731-5550 if you require further information.

MEDICATION ALLOWED

Anti-psychotics and Anti-depressants

MEDICATION NOT ALLOWED

Prescribed and "over the counter" (OTC) medications which Residents may NOT use when attending Sancta Maria House

include Benzodiazepine type medications and all medication medications with codeine:

Residents must have stopped taking these medications at least five days before coming to Sancta Maria House.

Generic Name Brand Name Generic Name Brand Name

Aprazolam Xanax

Bromazepan

Chlordiazepoxide Librium

Clonazepam Rivotril/Klonopin

Clorazepate Tranxene

Diazepam Valium

Estalzolam Prozom

Flurazepam Dalmane

Lorazepam Ativan

Oxazepam Serax

Temazepam Restoril

Triazolam Halcion

Opiates/Narcotics

Methadone

ASA with Codeine - 222, 223, 224

Tylenol (Acetaminophen) #1, #2

Any cough syrup with Codeine or Dextromethorpnan

Prescribed:

Generic Name Brand Name

Tylenol #3, and #4 -acetaminophen/ codeine/ caffeine

Percodan -aspirin / oxycodone

Percocet -acetaminophen / oxycodone

Diphenoxylate Lomotil

Hydromorphone Dilaudid

Meperidine Demerol

Propoxypherie Darvon

Fentanyl transdermal Duragesic

Morphine sulfate Kadian Levophanol Levo-dramoran

*Tramadol Ultram*relatively new

*Tramacet

Revised 2012-01-14

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PRE-ADMISSION MEDICAL EVALUATION

Other over the counter: (containing pseudoephedrine) Generic Name Brand Name

Dimehydrinate Gravol

Diphenhydramine Benadryl

Sudafed

Nytol

Sleepeze

Sominex

Contact C

Neo-Citrin

Diphenoxylate Lomotil

Hydromorphone Dilaudid

Meperidine Demerol

Barbituates

Fioricet acetamenophen/butalbitel/caffeine

Fioricet with codeine

Fiorinal aspirin/butalbital

Fiorinal C (1/4, 1/2) aspirin/butalbital/codeine

Fiormal aspirin/butalbital/caffeine

Secobarbital Seconal,

Tuinal

Nembutal

Phenobarbital Other Sedatives

Chloral Hydrate

Meprobamate Miltown

Benzodiazepine - like ("Z" - drugs)

Imovane Zoplicone

Rhovane

Ambien 0r Ambien CR Zolpidem

Eszopiclone Lunesta

Starnoc

Revised 2012-01-14

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