BridgePoint Onsite Program Application

PART A Onsite Program Application Form

(Required for Retreats and Modules)
Previous Admission to BridgePoint*

YesNo
PROGRAM APPLYING FOR:*

Retreat (onsite)Module 1 (onsite)Module 2 (onsite)Body Trust
Preferred Retreat Date (if applicable):
Alternate Date:
Date Preferred Module 1 Date (if applicable):
Preferred Module 1 Date (if applicable):
Preferred Module 2 Date (if applicable):
Preferred Body Trust Date (if applicable):
Do you want to be added to the cancellation list? We will contact you if there is a last minute cancellation.

APPLICANT INFORMATION

Tell Us About You
Name*

First NameLast Name
Referral Source:*

Self-referralReferring Professional (SHA)Referring Professional (private practice)
If you were referred by a professional, provide name and contact info.
Approximate date last attended and any previous names used:
Pronouns
Why do we ask this? Asking and providing pronouns helps everyone avoid assumptions and feel comfortable.
Are you willing to share a room? You will receive a private room unless otherwise indicated.*

YesNo
What is your current Gender Identity? *
What was your sex at birth?
Do you require a female-only program?*

YesNo
Saskatchewan Health Card #*
What former Saskatchewan Health Region Network do you live in? *
If you don't know, check out this map! https://www.saskhealthauthority.ca/sites/default/files/2023-02/map-academics-and-learning-lec-networks-map_1.pdf
Do you live in an urban or rural setting? *
AGE*
Date of Birth*

MonthDayYear
MM-DD-YYYY
Permanent Address *
Town or City*
Province
All participants must be permanent residents of Saskatchewan
Postal Code
Phone Number*
Provide a phone number where a voicemail can be left.
Email Address*

Confirmation EmailI hereby give my consent to receive emails from BridgePoint Center Inc. regarding [specific purpose, e.g., updates, promotions, newsletters], and I unhat I can withdraw my consent at aderstand tny time
Preferred Method of Communication

PhoneEmail

SAFETY CONTACT

Who is your Safety Contact? This person is authorized to share/receive your information in the event of a safety concern or medical event.
SAFETY CONTACT: Name *
SAFETY CONTACT RELATIONSHIP: (spouse, friend, etc)
SAFETY CONTACT ADDRESS:
SAFETY CONTACT: Phone Number*
SAFETY CONTACT: Email

WAIVERS & UNCONDITIONAL PROGRAM RELEASES

Thank you for reviewing all waivers, consentsand program releases prior to signing.
WAIVERS & UNCONDITIONAL PROGRAM RELEASES

I RECOGNIZE that the reason I am attending BridgePoint is due to my eating disorder, which by its very nature threatens my life. I therefore intend to relinquish my legal rights to the extent that I intend to fully assume the risks for any injuries or physical harm that may come to me for the duration of my stay at BridgePoint.

I HEREBY REMISE release and forever discharge BridgePoint and the Saskatchewan Health Authority from any liability, actions, suits, damages, claims or judgments that may result from any injury to my property or person for any reason whatsoever, including but not limited to any act or omission of BridgePoint or its agents, whether negligent or otherwise.

I AM VOLUNTARILY participating in residential programming by BridgePoint. I am signing this document of my own free will.

CONSENT NO SELF-HARM CONTRACT
I agree that should I experience feelings of wanting to physically hurt myself during my stay at BridgePoint, I will approach a BridgePoint team member for support prior to carrying out such actions. I understand that the BridgePoint team, in consultation with me, will implement measures to ensure I remain physically safe until such time that I am verbally and physically able to demonstrate no further thoughts of self-harm. Such safety measures may include:
- Allowing staff to monitor me until such time as my feelings and behaviors of self-harm are able to be controlled by me;
- Transfer to hospital via emergency medical services if my needs, as assessed by BridgePoint team members, are determined to be too acute to manage at BridgePoint. This contract will remain valid during my entire stay(s) at BridgePoint.
CONSENT PROGRAM PARTICIPATION
I consent to participate in all programming offered during my residential stay(s) at BridgePoint. In giving my consent, I agree to abide by and follow all walls and boundaries governing the operation of the program. I also agree to participate in all program activities in facilitating my recovery process to the best of my ability. I am aware that BridgePoint is not responsible for loss or damage sustained to any personal property I bring with me to the program.

ADULT CONSENT FOR MEDICAL TREATMENT
BridgePoint Center Inc. (herein after referred to as "BridgePoint") in Milden, Saskatchewan, utilizes physician, hospital and ambulance services in Outlook and Rosetown. Transportation to larger centers occurs only when the local community cannot adequately meet services, or when specifically requested by the individual receiving treatment. Individuals attending BridgePoint Programs are fully responsible for the cost of their personal medications whether covered under insurance plans or not.

I give consent to BridgePoint to utilize their community physician to provide for my routine health care needs while attending BridgePoint programs. In the event I require emergency medical treatment, I give consent to be treated at either the Outlook or Rosetown Hospital.

I am aware that I am responsible for all financial costs incurred for ambulance service and/ or other approved transportation. I give consent to only being stabilized at Outlook or Rosetown Hospital, and then transferred as soon as possible to the hospital of my choice for further treatment. I am aware that I am responsible for all financial costs incurred for ambulance service and/or other approved transportation. When Outlook or Rosetown hospitals are unable to accommodate our needs, I give consent to treatment at other health facilities in the SHA as discussed on a case by case basis with BridgePoint and Mental Health and Addictions Services.
SELF-MEDICATION PROGRAM POLICY ADULT

Upon admission to any of BridgePoint's Programs, Participants will give consent in written form to participate in the Self Medication Program. Whenever possible this program will be designed to meet the Participant's specific needs. Upon admission, the Nurse or team member will review the medications with the Participant. Participant will identify medications, reason for taking the medication(s), dose, time of day taken, duration taken, effectiveness, and any noted side effects. Each Participant will bring a sufficient supply of currently prescribed medication(s) as well as any over-the-counter medication(s) needed during their stay at BridgePoint. If there is any discrepancy between Participant stated dose and prescribed dose, the Participant's home doctor will be contacted as soon as possible. His decision will be documented in the Participant's chart, and will be acknowledged as the current prescription. All medication will be surrendered to the BridgePoint Team. All medications are kept in a locked room. Participants will have access to their individual medications via a BridgePoint Team Member. A weekly dosette will be provided for each Participant. The Nursing Associate(s) will supervise the Participant in filling or refilling the dosette. At all times Participants will self-administer medication, in the med room, in the presence of a team member. Following each self- administration, the Participant will document self-administration by initialing on the provided form. Team Members will check documentation at 2300 hours to determine Participant's medication compliance. Noncompliance will be documented in the Participant's progress notes. Medication noncompliance will result in the Participant's stay at BridgePoint being reviewed by the Team. Should a Participant require medical intervention from a local physician, any new medications prescribed will be reported and immediately surrendered to a BridgePoint Team Member who, if not a nurse, will ensure that the Nursing Associate is advised. The Nursing Associate will document the new medication in the charts, progress notes and inter-agency report. Under no circumstances will Participants provide any medication of any type or form to other Participants. Any sudden decrease or discontinuation in laxative use is potentially lethal. Seek BridgePoint Team assistance in determining medically safe ways to alter laxative dependency.

I acknowledge that I must bring all medications blister packaged by a pharmacist. If not possible, all medications and PRNs must be brought in original containers.
I acknowledge that I have read and executed the releases mentioned above by signing here:*

Clear
Date

MonthDayYear
Date
CONSENT FOR RELEASE OF INFORMATION
I hereby consent to allow BridgePoint Center Inc. (hereinafter referred to as "BridgePoint") to release information from their clinical records:
DOCTOR: Name and address of individual andor agency to receive information
COUNSELLOR: Name and address of individual andor agency to receive information
PHARMACIST: Name and address of individual andor agency to receive information
PSYCHIATRIST: Name and address of individual andor agency to receive information
DIETITIAN: Name and address of individual andor agency to receive information
FAMILY MEMBER or FRIEND: Name and address of individual andor agency to receive information
This consent will expire only upon written notification, from you (Participant), advising BridgePoint "consent is withdrawn", and by specifically naming to whom you do not want information released.
Participant Signature*

Clear
TERMS OF SERVICE

Saskatchewan Health Authority Mental Health and Addictions Services In Partnership with BridgePoint Center Inc.
Welcome to Mental Health and Addiction Services working in partnership with BridgePoint. As you and/or your child work together with your Service Provider, options for care and service will be explained so that informed decisions can be made, and goals set. As part of providing service to you, your assigned Service Provider will need to collect and record personal information that is relevant to your current needs. Goals and a treatment plan for counselling that includes approximate length of therapy will be developed with your clinician and regularly reassessed to ensure a successful outcome. To assist with treatment planning, the service plan that you and/or your child develop with your Service Provider, will be documented and may be shared with current and future assigned members of your treatment team. Such individuals may include but are not limited to Psychiatrists, Family Physicians, other Community Service Providers, and the person who referred you to Mental Health and Addictions Services. Mental Health and Addictions Services develops a case file on MENTAL HEALTH AND ADDICTION INFORMATION SYSTEM (MHAIS) regarding services provided for all individuals. There are laws and policies that regulate how information is to be kept, when it can be shared and with whom. At any point, you can request to have access to your file. You will be provided the requested documents or the reason the documents cannot be provided according to legislation. You can also request at any time to see who has had access to your file. Confidentiality is limited by requirements of the Criminal Code of Canada, the Child and Family Services Act, the Mental Health Services Act, and the Health Information Protection Act. Information will be released under the following circumstances:
1. You request information be shared with another individual or agency, and sign a release statement.
2. There is reason to believe there is serious and imminent risk of harm to you or others.
3. There is reason to believe that a child is in need of protection.
4. Information is required by law or the Courts;
5. Inpatient care or treatment is required within the Saskatchewan Health Authority or partnering agency.
6. There is reason to believe that you pose a risk to operate a motorized vehicle and/or airplane.
Your clinical record will be maintained for 10 years and your child's clinical record will be maintained 20 years after you complete services in a secure location. If you feel unclear at any time about the issue of confidentiality, or would like a copy of these regulations, please let your service provider know. A request may be made of you and/or your child to participate in training activities. Participation is optional. Your service provider may be in a provisional/probationary period and will be working under the direct supervision of a fully qualified supervisor.

Clinical supervision is provided to all staff, and files will be reviewed for supervision purposes.

Part of treatment is providing a safe environment for all clients and staff. This includes refraining from using substances prior to coming to appointments and during programming, and not bringing items or weapons to the center that could harm self or others. BridgePoint has a scent free and peanut free policy; therefore, we ask you to refrain from using fragrances and bringing peanut products. Thank you for your attention to these important details. I understand the above Terms of Service as explained to me and/or my child. | also understand that I may ask for a review of these terms at any time and have the right to ask questions about the services I, or my child, receives, to make my own suggestions and to discontinue services at any time.
Participant Signature*

Clear

	None	Past	Current
Overeating/bingeing
Purging (vomiting/laxative use)
Undereating/restricting
Excessive or compulsive excercise
Dieting or calorie counting
Use of diuretics, laxatives or diet pills
Other (ARFID, etc) - please elaborate below

	Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree
1. I have fun with others.
2. I feel like I don't have a life.
3. I have a close relationship with at least one best friend or partner.
4. I have trouble concentrating.
5. My health is more important to me than my physical appearance.
6. My life is full of worry right now.
7. I show my true self to others.
8. I have lots of rules about food.
9. I have lots of energy.
10. I feel connected to others.
11. I get satisfaction from my main activity (e.g. school, work).
12. I think about food constantly throughout the day.
13. I see positive things in my appearance.
14. I can allow myself to relax.
15. I skip meals on purpose.
16.I have fights with my family members about food or eating.
17. Every day is a struggle.
18. The number on the bathroom scale is very important to me.
19. I turn down opportunities to go out with friends.
20. I can focus on things other than food.
21. I feel hopeful about the future.
22. People don't understand me.
23. I don't go out with friends if I feel bad about my body.
24. I enjoy participating in different activities, not just exercise.
25. I'm constantly trying to fix my body.
26. I am able to see good qualities in myself.
27. I have plans for the future.
28. I feel understood by someone in my family.
29. Thoughts about food and eating dominate my life.
30. I put myself down a lot.
31. I feel self-conscious about my body around others.
32. My sleep is restful.
33. I feel comfortable eating in front of people.
34. The eating disorder affects what I can do every day.
35. I do things I normally wouldn't do because of my eating disorder.
36. I can consider my own happiness when making choices.
37. I feel like nothing I ever do is quite good enough.
38. I'm obsessed with my weight or body shape.
39. The eating disorder has taken over my life.
40. I feel physically cold.

	Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree
School work
Family and Close Relationships
Relationships with Others
Your future
Your feelings
Your appearance
Your Leisure (Free time activities)
Your values and beliefs
Thinking and concentrating
Your General Physical Health
Your Psychological Health
Your Health Related to Food & Weight

PART A Onsite Program Application Form

APPLICANT INFORMATION

SAFETY CONTACT

EATING DISORDER BEHAVIOURS & CURRENT HEALTH

PARTICIPANT PROFILE STATS

WAIVERS & UNCONDITIONAL PROGRAM RELEASES

CONSENT FOR RELEASE OF INFORMATION

TERMS OF SERVICE

EDQLS - EATING DISORDER QUALITY OF LIFE SCALE