Download Esquao© Healing Lodge

Esquao© Healing Lodge
Is our aftercare facility that provides a
healing environment to our women in
the surrounding community.
This 20 bed facility is located in St. Albert, AB. Esquao’s current programs are
focused on giving women independence
by providing role models, skills development, and guidance on how to achieve
their life goals.
Our Partners:
Esquao©
Healing Lodge
The programs delivered are focused on
the Cultural Role of Women, financial
education, leadership development, and
advocacy.
They will focus on continued recovery and healing with significance placed on Aboriginal women’s
health determinants and the road to
independence.
An aftercare facility that provides
a safe environment for women to
continue their recovery process
through traditional healing and
culture.
Esquao Healing Lodge
21 Meadowview Drive
St. Albert, AB T8N 2R9
Phone: 780.458.1884
Fax: 780. 459.1876
E-mail: [email protected]
www.poundmakerlodge.com
Esquao© Healing Lodge
Esquao© Healing Lodge
Program Components:
Poundmaker’s Lodge Treatment Centres
are known as Canada’s first addictions
treatment centre specifically for Aboriginal clients. It is important to note that
while our program focuses on Aboriginal
culture and spirituality, its principles are
universal. Clients from all cultures, traditions and faiths are welcome.
Application for Admission:

Application form completed by client and/or referral

Medical form to be completed by
physician
Admission Criteria:

All legal, medical, educational, employment, and child care services
must be dealt with prior to admission.

Must be 18 years of age or over

Free from all mind-altering substances while a resident.


No mood-altering substances are
approved for use while in staying at
Esquao Healing Lodge.
Clients stabilized on a current
methadone program are approved
on a case-by-case basis.
Financial Requirements:

For clients residing in Alberta:
$40/day

For clients outside of Alberta:
$150/day

For clients outside of Canada:
$250/day
Esquao© Independence Program
The Institute for the Advancement of Aboriginal Women (IAAW) will be delivering
the programming for the women staying at
the Esquao Healing Lodge. IAAW’s goal is to
help revive the women’s strength, wisdom
and vision of the future by providing the
skills, teachings and opportunities to improve
themselves personally and professionally
through the Esquao house. The programming
will include topics such as:





Self Discovery
Money Management & Financial Literacy
Facing Fears
Conflict Resolution
Building healthy, safe relationships
The Medicine wheel teaches us that in order
to live a healthy life we must have balance in
the four dimensions
of ourselves: the
mental, the physical,
the emotional and
the spiritual. It is
our belief that addiction destroys these
dimensions and the
only effective method of recovery is a
holistic approach. Our program combines
traditional Aboriginal spirituality with 12 Step
Programs and information lectures, to help
clients restore balance to their lives.
Clients reconnect with their culture, spirituality and themselves through sweatlodge ceremonies, smudging ceremonies, and sweetgrass ceremonies with the guidance of an onsight cultural advisor and elder. The clients
also participate in our annual cultural engagement activities such as; Métis Festival,
round dance and pow wow.
All activities at the Esquao© Healing Lodge
are conducted with an emphasis placed on a
deep respect for Aboriginal natural laws,
traditions and values.
Esquao© Healing Lodge
This 16 bed women’s residential facility is located in
St. Albert, AB. The program will focus on continued
recovery and healing with significance placed on
Aboriginal women’s health determinants and the road
to independence. The Esquao © Healing Lodge will
Esquao© Healing Lodge St. Albert, AB
engage clientele from the First Nations, Métis and
Inuit communities and those who may feel a culturally
based program can support their healing and recovery.

16 beds

Females only

Long term stay ie up to a year

Must be 18 years of age or older

Free from all mind-altering substances while
a resident

Clients stabilized on a current methadone
program are approved on a case-by-case
basis.
The Medicine Wheel

For clients residing in Alberta: $40/day

For clients outside of Alberta: $150/day
The Esquao© Healing
Lodge is part
of
the
Poundmaker’s Lodge Treatment Centres broader
commitment to initiatives that assist and engage the
Aboriginal community to achieve increased health
Esquao© Healing Lodge
outcomes. The facility will provide ongoing elder and
cultural supports as well as psychological supports
utilizing an Aboriginal therapeutic community model
which will allow women to make a difference in their
communities.
Ph: 780.458.1884
Fax: 780.459.1876
St. Albert, AB
WWW. POUNDMAKERLODGE.COM
POUNDMAKER’S LODGE TREATMENT CENTRE- Esquao Healing Lodge
(Mailing Address)
Box 34007, Kingsway Mall Post Office
Edmonton, AB T5G 3G4
Website: www.poundmakerlodge.com
Phone: (780) 458-1884
Fax: (780) 459-1876
Toll Free: 1(866) 458-1884
Application for Admission
1. Application Form completed by client and/or referral.
2. Medical Form to be completed by physician.
Admission Criteria
1. All legal, medical, educational, employment, and child-care services must be dealt with prior to
admission so as not to interfere with your treatment program.
2. Must be 18 years of age or over.
3. Free from all mind-altering substances for a minimum of 72 hours prior to admission date.
4. Clients stabilized on a current methadone program are approved on a case-by-case basis, please
contact the admissions department.
Financial Requirements
1. For clients residing in Alberta (must provide a current and valid Alberta Health Care number on the
application form);
Treatment service charge of $40 per day. Must provide a written confirmation letter from the agency
approving the treatment service charge OR provide a certified check, money order or bank draft for the
full amount upon admission for treatment.
2. For clients residing in Canada (excluding Alberta);
Treatment service charge of $150 per day. Must provide a written confirmation letter from the agency
approving the treatment service charge OR provide a certified check, money order or bank draft for the
full amount upon admission for treatment.
3. For clients outside of Canada;
Treatment service charge of $250 per day. Must provide a written confirmation letter from the agency
approving the treatment service charge OR provide a certified check, money order or bank draft for the
full amount upon admission for treatment.
What to Bring
An ankle-length nightgown (ladies), an ankle-length skirt (ladies) for ceremonies, toiletries (soap,
shampoo, etc.), proper footwear and clothing for recreational activities, appropriate swimwear for
swimming (no two-piece or see through). If applicable, please bring enough of your prescription
medications (preferably in blister packs) to last the length of your treatment.
1
Revised January 2012
Application for Admission
Which Program Are You Applying For? (Please check mark only one box below)
42 Day Drug / Alcohol Program
42 Day Gambling Program
14 Day Follow-Up Program (*Must have previously completed a residential
treatment program and have maintained sobriety since completion)
Esquao Healing lodge
Personal Information
First Name:
Last Name:
Other Name Used:
Other Last Name Used:
Mailing Address:
City / Town:
Province / State:
Postal / Zip Code:
Home Phone:
Cell Phone:
Date of Birth:
Month
/
Day
/
Year
Age:
Gender:
Male
(Please Circle)
Marital Status:
Single
Married
Divorced
Separated
Widowed
Ethnicity:
Status
Non-Status
Metis
Inuit
Non-Aboriginal
Treaty Status
On-Reserve
Off-Reserve
Not Applicable
(Please Circle)
(Please Circle)
(Please Circle)
Female
Common-Law
Band Name and 10-Digit Treaty Number:
AB Health Care Number:
SIN Number:
Education:
Occupation:
If prescriptions are required, how will they be paid for? (ie. SFI Recipient Number, Blue Cross Number, etc.)
Next of kin to be notified in case of emergency:
Relationship to applicant:
Phone Number:
Full Address:
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Revised January 2012
Referral Worker Information
(to be completed by referral, if no referral worker please write “Self” and skip to next section of Application)
Name of Referral:
Title:
Agency Name:
Agency Address:
City / Town:
Province / State:
Postal / Zip Code:
Agency Phone:
Agency Fax:
Additional Information
(to be completed by referral and applicant)
Would you be coming to treatment under one of the following conditions listed below? (please circle)
* Federal:
Parole
* Provincial: Probation
Other:
Statutory Release
Unescorted Temporary Absence
Recognizance
Conditional Sentencing Order
Temporary Absence
Temporary Release
Child Welfare
Employment Reasons
Not Applicable
If applicable, what is your offence (s):
Name of Probation / Parole Officer:
Address, Phone and Fax Number:
(* All legal papers to be submitted along with application form)
Details of any previous treatment for addictions:
Approximate Date:
Where (Institution / Agency):
Approximate Date:
Where (Institution / Agency):
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Revised January 2012
Approximate Date:
Where (Institution / Agency):
Motivation for entering treatment:
Please list the names of any substances used, how long you have been using, and when last used:
Substance:
For how long?
Last used:
Substance:
For how long?
Last used:
Substance:
For how long?
Last used:
Substance:
For how long?
Last used:
Medical Information
If you are currently taking any medications, please list the names of medications and what it is taken for:
Medication:
Taken for:
Medication:
Taken for:
Medication:
Taken for:
Health Problems:
Suicidal Behavior (Thoughts, Previous Attempts):
4
Revised January 2012
Referral Recommendations
(to be completed by referral)
Special needs / circumstances that may affect client’s treatment:
Referral’s assessment of the applicants motivation for entering treatment:
It is the policy of this treatment program that any person being admitted for treatment must be free of
alcohol and all illicit substances for a period of 72 hours prior to admission. I understand and agree to
accept the treatment program as prescribed as well as adherence to all treatment house rules.
Applicant’s Signature
Referral’s Signature
Date of Application
5
Revised January 2012
POUNDMAKER’S LODGE TREATMENT CENTRE- Esquao Healing Lodge
(Mailing Address)
Box 34007, Kingsway Mall Post Office
Edmonton, AB T5G 3G4
Website: www.poundmakerlodge.com
Phone: (780) 458-1884
Fax: (780) 459-1876
Toll Free: 1(866) 458-1884
Medical Information
(to be completed by a physician)
Note: This medical information is used as part of an application for admission to treatment at Poundmaker’s
Lodge Treatment Centre. Your patient is responsible for any fees associated with this service. No
mood-altering substances are approved for use while in treatment at Poundmaker’s Lodge, including
but not limited to benzodiazepines, opiods, and barbiturates.
Full Name of Patient:
AB Health Care Number:
Name of Physician:
Office Phone:
Office Fax:
Substance Abuse History (including alcohol, illicit substances, IV drug use, withdrawal symptoms, etc.)
Current Medications; please list the names of medications, dosages and what it is taken for:
Medication:
Dosage:
Taken for:
Medication:
Dosage:
Taken for:
Medication:
Dosage:
Taken for:
Allergies:
6
Revised January 2012
Is This Patient Pregnant? If so, how far along? Any complications?
Communicable Diseases:
Psychiatric History:
Special Dietary Requirements:
Physical Examination: Height
Weight:
BP:
Pulse:
Physical Notes (ears, nose, throat, skin, lungs, heart, etc):
Additional Comments:
Physician’s Signature
7
Date
Revised January 2012