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Enaahtig Healing Lodge and Learning Centre
INITIAL CONTACT SHEET (ICS)
Date of
contact:
Completed
by:
Agency/
Employer:
Face-to-Face/In-Person
Telephone
Other
The information requested will guide the development of your plan of care. All information is voluntary.
DEMOGRAPHIC INFORMATION
Person Requiring Care If applicable: ___________________ Relationship to Person:
_________________
Client Name:
Date of Birth:
Spirit Name:
MM/DD/YYYY
Gender:
Phone Number:
Cell/Alternate
Emergency:
Email:
Address:
Mailing
If different
Self Identification:
First Nation
Métis
Inuit
Other: ____________________________________
Status Card:
Métis Citizenship #
Clan:
Community:
Are you a descendant of a Residential School Survivor?
Survivors Name:
Relationship to
Survivor:
Contact Information:
Yes
Alive
No
Deceased
Band Number:
Name of School:
FAMILY COMPOSITION
Relationship
Status:
Children:
Child Name
Single
Married
Yes
No
Gender
Common Law
DOB
Divorced
Child Name
Separated
Gender
Widowed
DOB
EDUCATION & WORK HISTORY
Education:
Elementary: _______________________
Post-Secondary:
Secondary: ______________________
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Enaahtig Healing Lodge and Learning Centre
Income:
Employed Ontario Works
Employment:
ODSP
CPP
Benefits
Other:
PRESENTING ISSUES
Spiritual
Emotional
Physical
Mental
CURRENT COMMUNITY SUPPORTS
Check off the community supports client is currently utilizing
Seeking Treatment
Justice
Child Welfare
School Boards
Health
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
REFERRAL TO COMMUNITY SUPPORTS
Seeking services for: Counselling Traditional Healing Addiction Treatment Residential
School Support Primary Health Care Justice Support Child Welfare Other: ___________________
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Enaahtig Healing Lodge and Learning Centre
Referral To
Requested Services
1.
2.
3.



Referral Source:
Self
Referral Received



Agency (specify) ______________
Follow Up
Date/NA



Other_____________________
Personal Information and Consent Notice
Issues dealt with at your agency:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_____________________________________
Progress Observed:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
___________________________________________
Present Health Status:______________________________________________________
Aftercare Agreement
Enaahtig requires referring agents, who have established a healing relationship with a person
referred, to agree to provide appropriate aftercare for that person. This is to ensure a continuum of
care if needed. If you have established a healing relationship with any person referred by this
form, please complete the following.
Do you agree to provide aftercare for any person(s) referred on this form that you have established
a healing relationship with as deemed appropriate? Yes______
___________________________________________
Signature and title of referring agent
No______
____/_____/_______
Month Day Year
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Enaahtig Healing Lodge and Learning Centre
This Notice and Consent is intended to inform you how we will collect, use and disclose and
destroy your personal information.
Your personal information may be collected formally, in writing, and informally.
Only necessary information will be collected about you. We will collect, use, and disclose
information about you for the following purposes:
1. To develop plans of care and practice case management of your file;
2. To enable accurate referrals are made;
3. For anonymous statistical analysis of programs and services.
The storage, retention, and destruction of your personal information complies with this agency’s
policy, applicable legislation and privacy protection protocols. We are willing to provide a copy
of our policy to you at your request.
Your consent may be withdrawn at any time by written notice to this agency.
You may access you own personal information or request corrections through a written request
to this agency.
This consent form will serve for all agency programs you access, with one program designated as
your primary provider and your original consent kept in that program file.
Individual Consent
Always complete this part if the Individual is capable of consent. Individual refers to “client.”
I, _________________________________ (“The Individual”) have read and understood the
preceding Notice and had it explained to me. I am aware how this agency will use my personal
information. I am also aware of the steps taken by this agency to protect my information, when
it is collected, used or disclosed as well as how it will be stored and destroyed. I consent to the
provisions of the preceding Notice.
Signature: ________________________________
_______________________________
Date:
Witness: _________________________________
_______________________________
Date:
Complete this part if the individual is under 12 years of age, is incapable of consent or if an
individual has been assigned to act on his or her behalf.
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Enaahtig Healing Lodge and Learning Centre
I am the __________________ (parent, guardian, surety, etc) of the individual. I have read and
understood the preceding notice and had it explained to me. I consent on behalf of the
individual to the provisions of the preceding notice.
Signature: ________________________________
__________________________________
Date:
Name: ___________________________________
Witness:
________________________________
Consent to Exchange or Release of Confidential Information
I, ___________________________ (Name – Parent or Child / Youth if able) consent on behalf of
myself
Or
____________________________ (Name of child) and my family to a referral to:
Barrie Area Native Advisory Circle
____________________________________________________________
Barrie Native Friendship Centre
____________________________________________________________
Beausoleil First Nation
____________________________________________________________
Biminaawzogin Regional Aboriginal Women’s Circle
___________________________________________________________
Enaahtig Healing Lodge and Learning Centre
__________________________________________________ ___
Georgian Bay Native Friendship Centre
_____________________________________________________
Georgian Bay Native Women’s Association
_______________________________________________________
Métis Nation of Ontario
______________________________________________________________________
Orillia Native Women’s Group
_________________________________________________________________
Chippewas of Rama First Nation
________________________________________________________________
S.U.N. Housing
______________________________________________________________________________
CSC Chigamik
______________________________________________________________________________
Simcoe CAS ________________________________________________________________________________
Other
______________________________________________________________________________
_______
Total # of Agencies Consented: ______
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Enaahtig Healing Lodge and Learning Centre
I also consent to the exchange and/or release (please circle) of personal information from this
agency to the agency(ies) marked below and to allow the agency(ies)marked below to share
personal information collected about me and my family with this agency:
Barrie Area Native Advisory Circle
Barrie Native Friendship Centre
Beausoleil First Nation
Biminaawzogin Regional Aboriginal Women’s Circle
Enaahtig Healing Lodge and Learning Centre
Georgian Bay Native Friendship Centre
Georgian Bay Native Women’s Association
Métis Nation of Ontario
Orillia Native Women’s Group
Chippewas of Rama First Nation
S.U.N. Housing
CSC Chigamik
Simcoe CAS
Dr. Levene ,Ph.D., C. Psych.
Dr. Ed Connors, Ph.D., C. Psych.
Yvonne Brunelle
Other
For the purpose of assessment for programs and services and ongoing treatment of myself and
my family. This consent is valid for one year from the date signed. I understand that I can
withdraw this consent in writing at any time.
Total Number of Agencies: Click here to enter text.
Signature (Child / Youth): ____________________________________ Date:
_____________________________
Signature (Person Concerned/Parent): __________________________ Date:
_____________________________
Signature (Witness): _________________________________________ Date:
_____________________________
New
Renewed
Date: _______________________________
THE PERSONAL HEALTH INFORMATION PROTECTION ACT:
CLIENT INFORMATION SHEET
The Personal Health Information Protection Act, 2004 is a provincial law that governs the
collection, use and disclosure of personal health information within the health care system.
The object is to keep personal health information confidential and secure, while allowing for
the effective delivery of health care services. Under this legislation, health care providers
and others who deliver health care services are collectively known as health information
“custodians.”
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Enaahtig Healing Lodge and Learning Centre
What is personal health information?
Personal health information includes any identifying information about an individual’s
health or health care history, such as your family medical history, details of a recent visit to
your doctor, or your Ontario health card number.
Do health information custodians need my permission to access my personal health
information?
Custodians are permitted to collect, use and disclose your personal health information, on
the basis of implied consent, for the purpose of providing your health care.
What are heath information custodians required to do?
Under PHIPA, health information custodians are required to: 1) collect only the information
they need to do their job 2) take steps to safeguard your personal health information 3) take
reasonable steps to ensure your health records are accurate and complete for the work they
do 4) provide a written description of the practices they use to protect your information,
and the name of the person to contact if you have any questions or concerns about your
personal health records.
What are your rights under PHIPA?
PHIPA gives you the right to: 1) give permission (consent) to how your personal health
information is collected, used and shared 2) request access to your health records 3) make
corrections to your records.
For more information of your personal health information rights under PHIPA:
Service Ontario Information Line: 1-866-532-3162 (Toll-free)
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Enaahtig Healing Lodge and Learning Centre
ENAAHTIG CODE OF CONDUCT
The Code of Conduct of Enaahtig Healing Lodge is set of Standards that all people at the Lodge, both staff
and participants are expected to govern their behavior by. The Code is established to promote an atmosphere
of spiritual, emotional, mental and physical safety. We believe this to be necessary for the healing and health
of each of us and for the integrity of Enaahtig Healing Lodge. The following guidelines are central to our
Code of Conduct
1.
All persons at Enaahtig are expected to exhibit respect for others in their behavior, manner, and speech.
Accordingly, emotional abuse (e.g. insults, hurtful criticism, or verbal intimidation), physical violence or
intimidation will not be tolerated at any time.
2.
All persons at Enaahtig are expected to exhibit respectful relations with all of creation while at the
Lodge. Accordingly, persons must not hurt or damage plant o animal life or otherwise do anything
destructive to the land.
3.
All persons at Enaahtig are expected to exhibit respect to all races of humankind and their original
teachings in behavior, manner and speech. Furthermore, we are expected to exhibit respect and noninterference with the beliefs and spiritual paths of others.
4.
All persons at Enaahtig are expected to exhibit respect for the property of the Lodge and the personal
belongings of others. While at Enaahtig, the personal belongings of others are not to be used or
interfered with without the permission of the owners.
5.
Enaahtig is a drug and alcohol free area. Accordingly, no alcohol or non prescription drugs are to be
brought onto the property at any time.
Safety Precautions
For your safety, please observe the following safety precautions during your stay at Enaahtig. Please report all
accidents.
Ponds:
The ponds are a potential hazard for young children and we do not provide life-guard services.
Please supervise your children carefully while near the ponds to prevent accidents.
Horses:
We are prepared to offer instruction in horse-back riding but all interaction with the horses must be
overseen by a staff person. Please do not hand feed the horses at any time or step into their area
without staff supervision.
Beefallo:
These are a cross between regular farm cows/cattle and buffalo. Since they are part buffalo, they
should be considered unpredictable and potentially dangerous. Please stay away from them unless
you are accompanied by a staff member.
Kitchen:
The Enaahtig kitchen is a commercial one and we must follow health and Safety Code and Safety
procedures. Use of the kitchen, therefore, must be under supervision of an employee of Enaahtig.
Children are not permitted in the kitchen unless supervised.
Basement:
Because if the sensitive safety equipment in the basement and the steep stairway, it is potentially
hazardous are and is, therefore, off limits to all but Enaahtig employees.
Note: I have read Enaahtig Code of Conduct/Safety Precautions and I agree that I will follow them. I hereby waive any
legal and/or moral responsibility on the part of Enaahtig Healing Lodge and Learning Centre or it’s
representatives for any ill effects of my therapy, loss or damage to me or my property in or about
the property owned, leased or occupied by Enaahtig Healing Lodge and Learning Centre.
Client Signature:_________________________________________
Date:
_____/_____/____
Day Month Year
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Enaahtig Healing Lodge and Learning Centre
Consent to Intake/Treatment
The purpose of this form is to inform you of your rights and responsibilities in seeking help at
Enaahtig Healing Lodge and Learning Centre and to obtain your consent to conduct an intake and
to provide services.
During the intake interview, will ask you questions about your past and current life circumstances
and about the problems you seek healing for. You have the right to refuse to answer any of the
questions but it will help us if you do answer each of them. All information provided by you is
considered confidential. We will permit only members of our treatment team access t your
personal information and only then for serving you. Sharing this information outside Enaahtig
will be done only with you written permission. There are several limitation to your right to
privacy. If we ever come to believe that you are an immediate threat to yourself or others, we
would be obliged to report this to the appropriate authorities for the protection of all involved.
Also, files can sometimes be subpoenaed.
After your intake session, our treatment team will consider your issues and your healing goals and
then determine what service opinions we can offer you. Both you and the referring agent will be
contacted and you will be given the opportunity to either accept or decline services offered.
The primary obligations that you have in seeking services at Enaahtig Healing Lodge are to
assume responsibility for your personal healing and to respect Enaahtig’s rules while at the
Lodge. If you have any questions about your rights or responsibilities, you can contact us by
telephone or ask the Intake Coordinator.
Statement of Understanding and Consent
I understand that by signing this form I have acknowledged that I have read and understand the
information provided above and that I have given my permission to have an intake interview
conducted in order to offer treatment. Furthermore, I understand that this in no way obligates me
to Enaahtig Healing Lodge in any way.
(If consent is being given for a minor child, please indicate child’s name on the right)
____________________
Signature
_____/_____/____For:____________________________
month day year
(name of minor child of applicable)
______________________________
Witness
_____/____/_____
month day year
If you are signing for a minor child/ward, what is your relationship to the child/ward?
______________________________________________________________________________
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Enaahtig Healing Lodge and Learning Centre
Release of Personal Information Form
I,_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Full Name and Address)
authorize Enaahtig Healing Lodge and Learning Centre to disclose/request personal
information consisting of files, reports, documents, contact info concerning:
o
myself,
OR
o
_______________________________________________________,with
(Full Name of person for whom you are the legal caretaker )
and/or from the following agencies/organizations:
1._____________________________________________________________
2._____________________________________________________________
3._____________________________________________________________
Signature: _______________________________________ Date: _______________________
Witness:_________________________________________Date:________________________
Expiry Date:__________________________________
The personal information collected on this form will be used for the purpose of processing your request to share your personal
information as instructed above. It is collected under section 33 (c) of the Ontario Freedom of Information and Protection of Privacy
Act, and will be protected under its provisions. If you have any questions about the collection and use of this information, contact the
designated Department.
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Enaahtig Healing Lodge and Learning Centre
Medical Information Release Form
(to be filled out by medical professional)
Pre-Admission Medical Form
Physician:________________________________________
Phone___________________________________
Address:________________________________________________________________________________________
Client Name:________________________________________________________________
Date of Birth: ______/_____/_____
Month day year
Physical Condition: (includes communicable diseases, diabetes, heart problems, etc.)
________________________________________________________________________________________________
________________________________________________________________________________________________
Medication: _____________________________________________________________________________________
Allergies: _______________________________________________________________________________________
Psychological Condition: (medication if applicable)
________________________________________________________________________________________________
________________________________________________________________________________________________
Is client dis/alter abled?___________ If yes, please describe:_______________________________________________
________________________________________________________________________________________________
Special Diet indicated?_____________________________________________________________________________
Please note that clients may be participating in Native Ceremonies-Sweat/Teaching Lodges, Fasts, etc. During the
Sweat Lodge Ceremony, Participants will be experiencing heat and humidity similar to a Swedish sauna for up to two
hours. Any medical condition that you are aware of should be documented since it may affect their ability to participate
in some ceremonies.
Is client medically clear to participate in Sweat Lodge?_________
Fasting?______________
Medical Professional Signature:_______________________________________
Date: _____/____/_____
Month Day Year
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Enaahtig Healing Lodge and Learning Centre
Adult Residential Program
This is a 6 Day Residential Program that is designed for adult
individuals, male and female, that are beginning their healing journey. If
offers an environment to learn about the effects of trauma and healthy
ways of coping.
The strength of this program is the experiential learning and sharing that
occurs within the group process at the following themes are explored.
 Self Esteem, Boundaries
 Healthy Communication, Healthy Coping Strategies
 Historical Trauma (Inter generational impacts of Colonization)
 Grief and Loss, Anger Awareness
 Meditation and Healthy Living
As well, all residential programs are based upon a traditional and
cultural foundation. The use of Pipe Ceremonies, Prayers, Sweat
Lodge and Sharing Circles are integral to the healing environment.




To Attend this Program, Participants must be:
18 years of age or older
Must Be Drug and Alcohol Free for min. 30 Days
Must have a doctor or nurse practitioner complete medical
form
An Intake Application must be completed
Please Contact the Intake Coordinator at 1 (705) 534-3724 Ext. 230 or
via email at [email protected] if you are interested or have
any questions regarding the application process.
Please Note: Transportation services may be available within Simcoe
County if required.
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Enaahtig Healing Lodge and Learning Centre
Family Residential Program
The Family Residential Program is a 6 day residential designed to provide
families with a safe environment to strengthen relationships, foster
healthy communication and share positive experience and growth.
Children accompanying an adult must be under the age of 18 years of
age and all participants over the age of 18 must complete and application
package.
Activities and workshops include:
 Healthy Communication, using the “I statement”
 Feelings and Emotions, “All Feelings are Good”
 Impacts of Colonization
 Parenting styles and awareness
 Relationship building
 Cultural activities such as crafting, Sweat Lodge ceremony
 Lots of Family Fun and time with family doing seasonal outdoor
activities
Please Contact the Intake Coordinator at 1 (705) 534-3724 Ext. 230 or
via email at [email protected] if you are interested or have
any questions regarding the application process.
Please Note: Transportation services may be available within Simcoe
County if required.
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Enaahtig Healing Lodge and Learning Centre
Trauma and Recovery Program
The Trauma and Recovery Program is a 12 Day
residential program, adults only, for individuals
impacted by Residential School exposure, either
directly or indirectly (inter-generational).
The Central therapy used in this program is
Imagery Re-scripting and Reprocessing Therapy
(IRRT), which allows the individual to revisit
past traumas through adult eyes with supports to
overcome the pain and suffering it has caused.
The Sequence of workshops begin with the building of relationships within the group,
establishing trust, then moves into historical and childhood trauma, preparing participants
to experience the IRRT process. This is followed by self care and aftercare planning.
Due to the intensity of this work, a careful intake process is necessary for all participants
to ensure that the individual is in a state in their life, where they have the necessary
internal and/or external resource and supports to attend the program.
To attend this program, participants must be:
 18 years of age or older
 Must complete the intake referral and assessment process
 Must be free of Drugs and Alcohol for Min. 30 days
 Must have the medical clearance form filled out by a doctor or nurse practitioner
Please Contact the Intake Coordinator at 1 (705) 534-3724 Ext. 230 or via email at
[email protected] if you are interested or have any questions regarding the
application process.
Please Note: Transportation services may be available within Simcoe County if required.