Bringing The Spirit Home Detox Centre

Admissions Application & Service Contract

• Please complete all questions
• Application does not guarantee a bed
• An email will be sent to you advising you when we have received your application

Bringing the Spirit Home (BtSH) – Guidelines and Values

About Us

Bringing the Spirit Home (BtSH) is a safe withdrawal site in Standoff, Alberta, located on traditional Blackfoot Territory. We provide medical detox for adults (18+) through an Indigenous-based program that honors Blackfoot traditions and knowledge. Our center is inclusive and welcomes all individuals seeking healing.

Our Values

• Respect for all individuals and cultures
• Kindness (Kimmapiipitsinni) as a guiding principle
• Commitment to supporting healing and balance

Services

• 24/7 paramedic support for safe detox
• Daily schedule: meals, smudging, chores, group sessions, exercise, meditation, NA/AA, and one-on-one peer support
• Blackfoot Elders offering ceremonies, teachings, prayers, and storytelling

Respect and Safety Guidelines

To maintain a safe and supportive environment:

• No verbal or physical abuse toward anyone; violators will be asked to leave.
• Maintain confidentiality and respect personal space and belongings.
• Do not enter other clients’ rooms or store food in rooms.
• Explain disagreements calmly; avoid yelling or accusations.
• Use coping strategies to manage tension.

Additional Rules:

• Complete chores before TV privileges; only staff control remotes.
• Clean rooms and bathrooms daily; beds must be made.
• Suitcases and large bags will be stored securely; limited clothing allowed in rooms.
• Follow posted schedules for sessions and meals; groups are mandatory.
• No smoking, kitchen use, or pool during sessions.
• Garden access only with staff supervision.
• Visitors are not permitted.
• Offsite activities allowed after 5 days of detox.
• NA/AA meetings require staff presence.
• No mail service; intimate relationships are prohibited.
• Money stored in lockup; staff cannot accept e-transfers.
• Phone calls to family allowed after 4 days of detox, per schedule.

Things to bring:

• 3 pairs of comfortable clothing
• Slippers
• Cigarettes
• Ceremonial clothing

What NOT to bring:

• Paraphernalia
• Perfume
• weapons
• Cellphones
• Any electronics
• Large amounts of cash
• Jewellery 
• Outside food, including snacks

* Basic toiletries (shampoo, soap, toothpaste, etc.) are provided, but you may bring your own.

     Prescribed medication can be transferred to Blood Tribe Pharmacy.

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Personal Information

Legal Name (last, first, middle) *

Date of Birth

mm-dd-yyyy

Age

Gender

Band

Treaty Number

Alberta Health Care

Marital Status

• Single
• Common Law
• Dating
• Married
• Divorced
• Widowed

Address

Address Line 1

City

State / Province / Region

Postal Code

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Phone Number

Who does this number belong to?

Emergency Contact

Emergency Contact Name/Relation

Three months ago, were you a resident of a province or territory other than Alberta?

• No
• Yes

If yes, what date did you take up residency in Alberta?

Type of Referral

Were you assisted with this application? Check all that apply.

• Addiction Service Worker
• Child Welfare Worker
• Social Services
• Assured Income for the Severely Handicapped (AISH)
• Physician
• Mental Health Worker/Psychiatrist/Psychologist
• Court/Probation Officer/Lawyer
• Other

If other, please list your choices

Self Referral

• Yes
• 10 Day Detox
• Treatment

If you chose Treatment, which facility are you planning to attend?

Post-Treatment (waiting for Residential Transition)

• Yes
• Bed Confirmation

vision/hearing for Date

Name of Transition Facility

Transition Phone Number

Substance Use

Drug of Choice

Date last used

Age of first use

Pattern of use (how often)

Drug of Choice

Date last used

Age of first use

Pattern of use (how often)

Drug of Choice

Date last used

Age of first use

Pattern of use (how often)

Drug of Choice

Date last used

Age of first use

Pattern of use (how often)

Health Profile

Do you have any concerns or challenges that may require additional support that we need to be aware of? (Mobility access, vision/hearing impairments, reading and writing English, etc.)

• No
• Yes

If yes, please provide details

Do you have any allergies (food, medication, environmental)?

• No
• Yes

If yes, please list allergies and common reactions for each

Do you have a family doctor?

• No
• Yes

Family doctor's name:

Doctor's Phone Number

Are you currently prescribed:

• Methadone
• Suboxone
• No

Prescribing Physician

Physician Phone Number

Prescribed Dosage

How long on medication?

Any Mental Health conditions (list or describe)?

Have you been professionally diagnosed (by a psychologist, psychiatrist, counsellor)? If yes, when and what was diagnosis? By whom?

Are there any medications that you are taking for your mental health? (Please list)

Legal Issues

Do you have any pending charges or outstanding warrants?

• No
• Yes

If yes, please list:

Do you have any pending and/or upcoming court dates?

• No
• Yes

If yes, please list date, place, and what they are regarding

Do you have a lawyer?

• No
• Yes

Lawyer name

Lawyer phone number

Carefully Read the Following

I have ensured that all the information I am giving in this application is true. I understand that if any of the information that I have given is found false (or pertinent information omitted), it will result in loss of eligibility to or dismissal from Bringing the Spirit Home (BtSH) program. I understand I am responsible for my transportation to BtSH. I am responsible for transportation if I choose to leave BtSH or if I am discharged for not following rules or programming. I understand BtSH is not responsible for cost of my medication. I will bring and give to staff all medications I am taking. I understand I must follow rules and programming at BtSH. I must focus on my healing and treatment planning. I understand and agree to the terms of services outlined in the Service Contract and follow rules outlined. By signing below, I am agreeing to the terms and services at Bringing the Spirit Home.

Name *

Date signed

Referral Information

To be completed on a professional basis; referrals from friends and family are not accepted. The referral will be the contact person for the applicant. The referral will assist with setting up treatment and travel Section to be completed by the referring person only.

Referring person's name *

Agency

Professional relationship to applicant

Business address

Address Line 1

City

State / Province / Region

Postal Code

--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Phone number

Fax number

Type of Referral

• AHS Addiction Services
• Other Addictions Agency
• WCB/Disability Management
• Health/Medical – Doctor
• Justice/Legal
• EAP
• Other

If other, please list

What is your assessment of the applicant’s readiness and motivation for detox? What is their plan for treatment?

Referral's signature *

Date signed

mm-dd-yyyy

Submit