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Applications

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

DOWNLOAD INFORMATION PACKAGE

OPTION 2: ONLINE FORM

KARIS APPLICATION

Step 1 of 15

6%

STEPS TO TAKE:
1. Read the information package.
2. Fill out all fields in order for your referral to be processed.
3. You will be contacted by Intake Staff within one week. Please ensure your contact information is accurate.

ADMISSION CRITERIA
● Willing to live in a community setting in a semi-structured recovery-centered residential program.
● Stability for residence in a non-medical setting.
● Expected to provide a substance-free urine screen upon arriving at Karis and before admission. Applicants that require medical withdrawal will be required to do so before entry.
● Active participation is an essential requirement of programming. If applying for the Parenting Program
● The Program can facilitate children up to the age of two-and-a-half years old.

What program are you applying for?(Required)

PARTICIPANT INFORMATION

Participant Information(Required)

First Name Middle Last Name

Preferred Name

Preferred Name Preferred Pronoun

Marital Status(Required)

Is the applicant experiencing homelessness?(Required)

If no, please provide the following info below

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

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

Persons With Disabilities (PWD)

Person of Multiple Barriers

Child Tax Credit

Other

Additional Notes:

CURRENT TREATMENT (IF RELEVANT)

Name of Centre

Address of Centre

Street Address Address Line 2 City Province Postal Code

Name

Agency Phone

Client start date and discharge date:

Support person contact (if applicable):

HISTORY OF SUBSTANCE MISUSE CONCERNS

ALCOHOL (beer / wine / hard 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)

FENTANYL

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?

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

Does the applicant have a BC medical/service card number?(Required)

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

In order for Karis to provide special dietary requirements, a doctor's note must be supplied.

Has applicant been hospitalized in the last 30 days?(Required)

If YES, please explain

Medication

Medication

Dosage

Reason Prescribed

Is the applicant on current harm reduction therapy?(Required)

If YES, which therapy?

Applicant's prescribing doctor

Applicant's prescribing doctor

Start date

Dosage

Has the applicant had a diagnosis of any of the following?

ADHD

FASD

Borderline Personality Disorder (BPD)

Autism Spectrum

Schizophrenia

Bipolar Disorder

Eating Disorder

Seizures

Head Injuries

Other:

If other, please explain:

What are the impacts on daily life? Please explain:

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

If YES, dates and reasons:

Does the applicant experience any limits to mobility?(Required)

(e.g. impairment)

If yes, are they in need of additional supports/accommodations?

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

LEGAL HISTORY

Has applicant been incarcerated previously?(Required)

If YES, what were the charges?

Does applicant have pending criminal charges?(Required)

If the applicant is currently incarcerated, where?

When is the expected release date?

Charge description:

Probation?(Required)

Probation Requirements (please explain)

Probation Details

Name of probation officer

Phone Number

Charge description

Has the applicant experienced Intimate Partner Violence?

Is the applicant currently in danger?(Required)

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

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

Community Supports

Life Skills Worker

Phone

Other Professional Community Supports

Is applicant currently in a relationship?(Required)

Are they safe?

Are they sober?

How will that affect their participation in the program?

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.

How can Karis support the applicant in any cultural, spiritual, religious practices or ceremonies while at Karis?

Ethnicity(Required)

Indigenous Ancestry?(Required)

Does the applicant currently have status?(Required)

Band

EMERGENCY CONTACT INFORMATION

Emergency Contact Name(Required)

First Last

Relationship

Relationship

Emergency Contact

Emergency Phone Alternative Phone

Emergency Contact Address

Street Address Address Line 2 City Province Postal Code

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 MISUSE

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)

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

What are your expectations for Karis Support Society?

How long do you expect to be at Karis?

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?

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.

Δ

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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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