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Be sure you have read the information package. In addition, you must fill out all required fields. Incomplete referrals will not be considered. After the referral has been sent, potential participant is required to call in weekly in order to remain on the wait list. The completed application package will be reviewed by the screening committee to assess eligibility into the program. Once you have submitted your application, please contact the Karis Intake worker at 250.860.9507 x115 to follow up and learn what your next steps are in the process. If you receive the answering machine, please leave a message with your name and the best contact # where you can be reached.

OPTION 1: DOWNLOAD & SUBMIT

DOWNLOAD the form below (right-click > save-as)
FILL it out on your computer
PRINT it
SEND it to us via EMAIL or FAX | applications@karis-society.org | (250) 860-9517 (FAX)

DOWNLOAD APPLICATION FORM

OPTION 2: ONLINE FORM

KARIS APPLICATION

Step 1 of 20

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Be sure you have read the information package. In addition, you must fill out all required fields. Incomplete referrals will not be considered. After the referral has been sent, potential participant is required to call in weekly in order to remain on the wait list. The completed application package will be reviewed by the screening committee to assess eligibility into the program. Once you have submitted your application, please contact the Karis Intake worker at 250.860.9507 x115 to follow up and learn what your next steps are in the process. If you receive the answering machine, please leave a message with your name and the best contact # where you can be reached.

ADMISSION CRITERIA
• Potential participants will be drug tested upon admission. If tested positive applicant will be declined acceptance into the program.
• Participants must be stable for residence in a non-medical setting. Applicants that require medical withdrawal will be required to do so before entry.
• Karis’s Parenting Program can only facilitate children up to the age of two-and-a-half years old.
• Participants must be willing to live in a community setting in a semi-structured recovery- centered live-in program.
• Participants must be capable of participating in programming. Active participation is an essential requirement of programming.

What program are you applying for?(Required)

PARTICIPANT INFORMATION

Participant Information(Required)

First Name Middle Last Name

Preferred Name

Preferred Name Preferred Pronoun

Agency Address(Required)

Street Address Address Line 2 City Province Postal Code

Participant Information

Mobile Home Phone

Email

Email

Care Card #(Required)

Care Card #

Date of Birth(Required)

MM slash DD slash YYYY

Date of Birth

SIN

SIN

Marital Status(Required)

REFERRAL INFORMATION

Referring Agent(Required)

Agent First Name Agent Last Name

Name(Required)

Agency Name Agency Email Address

Agency Address

Street Address Address Line 2 City Province Postal Code

Name

Agency Phone Agency Fax

INCOME

Income Assistance

Disability

Person of Multiple Barriers

Child Tax Credit

Other

Additional Notes:

Is securing employment part of your goals while at Karis?(Required)

HISTORY OF SUBSTANCE MISUSE CONCERNS

ALCOHOL (beer / wine / liquor)

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

CANNABIS (pot / hash)

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

COCAINE (crack / coke)

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

HALLUCINOGEN (acid / mushrooms / PCP / ketamine)

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

BARBITURATE (pennies / yellow jackets)

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

AMPHETAMINE (crystal meth / ecstasy / speed)

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

HEROIN (China white / crank)

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

OPIATE (morphine / codeine / opium)

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

INHALANT (glue / hairspray)

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

ILLICIT METHADOSE

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

BENZODIAZEPINE (sleeping pills / tranquilizers)

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

OVER THE COUNTER DRUGS (cough syrup)

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

TOBACCO

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

OTHER

age first used

frequency (daily / weekly / monthly)

amount

last used (mo/day/year)

DEPENDENT INFORMATION

Is applicant currently pregnant?(Required)

If yes, when is the due date?

Number of children in applicant’s care?(Required)

Children’s current living situation?

Does the applicant have MCFD involvement?(Required)

If YES, who is applicant’s social worker?

Social Worker's Phone

In what city does applicant have an open ministry file?

Children

Child's Name

Age

MEDICAL HISTORY

Allergies to Medication

Medical Coverage

Medical History

Family Physician

Phone

Any current health concerns (e.g. Diabetes, high cholesterol)?

Does applicant have any dietary restrictions?

(e.g. lactose intolerant, celiac)

If YES, please explain

Allergies?

If YES, please explain

History of hospitalization in the last 30 days?(Required)

Medication

Medication

Dosage

Reason Prescribed

Are you on current opiate maintenance therapy?(Required)

If YES, which therapy?

Are you allowed carries?(Required)

Medication

Prescribing Doctor

Start Date

Dosage

Duration of Therapy

History of seizures?(Required)

Are they withdrawal related?(Required)

If YES, please explain?

Head injury?(Required)

(due to assault, MVA etc.)

If YES, please explain?

Diagnosis of FASD?(Required)

Does applicant experience any limits to mobility?(Required)

If YES, are they in need of additional support/accommodation?

History or diagnosis of cognitive disorder?(Required)

(e.g. impairment)

If YES, are they in need of additional support/accommodation?

Last TB test?

MM slash DD slash YYYY

History of communicable diseases?(Required)

Communicable Diseases

HIV

HEP C, B or A

STD

MRSA

For checked boxes, please explain current treatment

MENTAL HEALTH HISTORY

Has applicant been diagnosed with any of the listed psychiatric disorders?

DEPRESSIVE DISORDER

BI-POLAR

SCHIZOPHRENIA OR OTHER PSYCHOTIC DISORDER

ANXIETY DISORDER

EATING DISORDER

PERSONALITY DISORDER (please specify below)

PERSONALITY DISORDER DETAILS

Is applicant currently in crisis?(Required)

(e.g. impairment)

What are the impacts on daily life? Please explain:

Does applicant currently have a wellness care plan?(Required)

Has applicant been hospitalized for mental health concerns in the past 6 months?(Required)

Dates

Reasons

COVID-19 VACCINATION RECORD

Immunization status(Required)

Immunization type

Date of first dose

Date of second dose

LEGAL HISTORY

Does applicant have pending criminal charges?(Required)

If YES, what were the charges?

Has applicant been incarcerated previously?(Required)

Up and coming court dates?

Probation?(Required)

Probation Requirements?

WEEKLY CHECK-IN

MONTHLY

OTHER (please explain)

Probation Requirements (please explain)

Probation Details

Name of probation officer

Phone Number

Charge description

COMMUNITY SUPPORTS

Community Supports

Family Physician

Phone

Community Supports

Dentist

Phone

Community Supports

Pediatrician

Phone

Community Supports

Alcohol & Drug Counsellor

Phone

Community Supports

Mental Health Worker

Phone

Other Professional Community Supports

How will these people support you in your recovery?

CULTURAL INFORMATION

We invite you to let us know if there are any cultural, spiritual or religious practices or ceremonies that will support your wellness while at Karis.

Ethnicity(Required)

Indigenous Ancestry?(Required)

Does the applicant currently have status?(Required)

Band

Specific care requested?

EMERGENCY CONTACT INFORMATION

Emergency Contact Name(Required)

First Last

Emergency Contact Address

Street Address Address Line 2 City Province Postal Code

Emergency Contact

Emergency Phone Alternative Phone

Relationship

Relationship

SAFETY CONCERNS

History of suicidal ideation / attempts?(Required)

History of self-harm?(Required)

History of aggression / aggressive behaviors?(Required)

Does the applicant have a care plan in place?(Required)

Is applicant currently in a relationship?(Required)

Are they safe?

Are they sober?

How will that affect their participation in the program?

Does applicant have a history of domestic violence?(Required)

Is applicant currently in danger?(Required)

Is there a no-contact order in place?(Required)

HOUSING / ACCOMMODATION

What is the applicant’s current housing status?(Required)

Are there safe housing concerns?(Required)

Is housing stable?(Required)

Has applicant accessed the following affordable housing options?

NOW CANADA

BC HOUSING

CMHA SUTHERLAND

JOHN HOWARD

(check all that apply)

If any of the above boxes were checked, what was the date applicant resided there and the reason applicant left?

Following completion of programming Is acquiring access to low-income housing part of applicant’s goals?

EDUCATION

Grade Completed(Required)

Check all that applicant has completed

HIGH SCHOOL

TRADE JOBS

COLLEGE DIPLOMA

UNIVERSITY

Has the applicant experienced any barriers to learning? Are they in need of extra support? Please describe

SUBSTANCE MISUSE TREATMENT HISTORY

Fill out any of the agencies / programs you've been a part of.

RESIDENTIAL TREATMENT

NAME OF AGENCY

DATES

COMPLETE / INCOMPLETE

SUPPORTIVE RECOVERY

NAME OF AGENCY

DATES

COMPLETE / INCOMPLETE

DETOX

NAME OF AGENCY

DATES

COMPLETE / INCOMPLETE

If incomplete, please explain

HISTORY OF OTHER ADDICTION CONCERNS

PORNOGRAPHY ADDICTION

DATE LAST ACTIVE

AGE AT FIRST EXPERIENCE

SHOPPING ADDICTION

DATE LAST ACTIVE

AGE AT FIRST EXPERIENCE

SEXUAL ADDICTION

DATE LAST ACTIVE

AGE AT FIRST EXPERIENCE

GAMBLING ADDICTION

DATE LAST ACTIVE

AGE AT FIRST EXPERIENCE

OTHER

DATE LAST ACTIVE

AGE AT FIRST EXPERIENCE

(hoarding, shoplifting etc.)

DISORDERED EATING

DATE LAST ACTIVE

AGE AT FIRST EXPERIENCE

(binging / overeating / restricting)

Check all of the boxes of programs you are currently attending

ALCOHOLICS ANONYMOUS (AA)

NARCOTICS ANONYMOUS (NA)

12 STEPS PROGRAMS

WELLBRIETY

ANOREXIC AND BULEMIC ANONYMOUS (ABA)

OTHER

Other program you're attending

SELF-ASSESSMENT

Strengths / needs / abilities / preferences

Why is supported recovery the best fit for you?

In your own words, what are your current challenges to maintaining a healthy lifestyle?

Why have you chosen Karis?

Are you aware that Karis is a faith-based organization?(Required)

Are you open to engaging with our faith-based programming?(Required)

Are you willing to go into treatment prior to coming in to Karis?(Required)

What are your expectations for Karis Support Society?

Karis Support Society offers participants to stay up to 2 years in the building. If accepted, how long do you believe you would like to be in our program?

What are your personal goals while at Karis?

Are you willing to be involved in intensive counselling?(Required)

Do you believe that your addictions are a problem to your well being?(Required)

Do you desire and have a willingness to change?(Required)

Are you willing to adhere to the Karis structure while in the program?(Required)

What is / are your motivation(s) for maintaining a recovery-based lifestyle?

What do you believe your strengths are (assets, resources)?

Needs (liabilities / weaknesses):

Abilities (skills, capabilities, talents):

Preferences (things you feel will enhance participant experience while within Karis):

Once you have submitted your application, please contact the Karis Intake worker at 250.860.9507 x112 to follow up and learn what your next steps are in the process. If you receive the answering machine, please leave a message with your name and the best contact # where you can be reached. Thank you. We look forward to hearing from you.

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Contact

550 Rowcliffe Ave.
Kelowna, BC
V1Y-5Y9

TEL 250.860.9507
FAX 250.860.9517

© Karis Support Society

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