The ASK Wellness Society would like to acknowledge that our programs and facilities operate on Secwepemcúl'ecw, Nłeʔkepmx Tmíxʷ, and Syilx tmixʷ traditional and unceded territories.

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Maverick Supportive Recovery (MSR) Referral Form

Maverick Supportive Recover (MSR) Referral Form

Referring Agency

Date

Name of Agency Contact

Phone/Mobile

Program Referring to:

Phase 1

Phase 2

Phase 3

Applicant Information

First Name

Last Name

Applicant Phone/Mobile

Date of Birth

Health Care Card Number:

Where is the applicant currently living? Is this sustainable?

The MSR Program catchment area is in the Thompson, Nicola, Chilcotin, and Shuswap. Where is the applicant’s home community?

Does the applicant have Hep C?

Yes

No

Does the applicant have HIV?

Yes

No

Is the applicant on OAT (Opioid Against Therapy)

Yes

No

Does the applicant have significant medical concerns? (We have access to a Health Navigator if needed). Please explain:

Does the applicant identify as First Nations, Metis, or Inuit?

Yes

No

If yes, please enter the name of their Band: (We have a Cultural Support Worker on site to support individuals with cultural healing and wellness.)

What is the applicant’s preferred gender identification?

Does the applicant have any current probation requirements or up coming court dates?

Yes

No

If Yes, Please describe

Is there a history of violence or assault?

Yes

No

If Yes, Please describe

What is the applicant’s source of income?

Basic Assistance

PWD

EI

Medical EI

CPP

Other

What is the applicants monthly income?

Is the applicant eligible for a security deposit from the ministry? (After three months a security deposit will be required if you plan on staying on for additional recovery support and/or career development).

Yes

No

Would the applicant have funds available for the daily rate of $35.90 program fee upon acceptance into the program?

Yes

No

ASK Wellness is COA Accredited

COA accreditation signifies that an organization or program is effectively managing its resources and providing the best possible services to all of its stakeholders. It also signifies that an organization or program meets standards of quality set forth by the COA accrediting body.

For more information about COA accreditation visit coanet.org.

Inclusive

The ASK Wellness Society is working towards providing and improving the available resources for 2sLGBTQ+ individuals in our communities by implementing 2SLGBTQ+ outlets at our sites and through advocating for 2SLGBTQ+ rights and respect. We welcome all and any members of the 2SLGBTQ+ community to access our resources.

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