If you got help from a referral worker to complete this form, please answer the questions below (light grey box). If not, go directly to the General Information section. ᐃᓱᐊᕐᓯᕕᓕᐊᕋᓱᐊᑐᐊᕈᕕᑦ ᐃᑲᔪᕐᑕᐅᓗᑎᑦ ᐃᓱᐊᕐᓯᕕᓕᐊᖁᔨᔪᑦ ᐱᓇᓱᑦᑎᖓᓄᑦ, ᐅᑯᐊ ᑭᐅᒪᒃᑭᑦ ᐊᐱᕐᓲᑏᑦ ᐊᑖᓃᑦᑐᑦ. Si vous avez obtenu de l'aide d'un travailleur de référence pour remplir ce formulaire, veuillez répondre aux questions ci-dessous.
Whom do you live with and what is your relationship to these people?*
What is your marital status?*
Single / ᐃᓄᑐᐊᖅ / Célibataire Common Law / ᐃᑦᑐᓱᒃ/ᓂᖏᐅᓱᒃ / Conjoint de fait Married / ᑲᑎᑎᑕᐅᒪᔪᖅ / Marié Divorced / ᑲᑎᑎᑕᐅᒪᒍᓐᓀᑐᖅ / Divorcé
How many children do you take care of (optional: provide details)?*
If you have kids, who will take care of them while you're at Isuarsivik?
Are you currently involved with the DYP?
No / ᐊᐅᑲ / Non Yes / ᐋ / Oui If yes, please indicate the name and contact information of your DYP representative
Are you currently employed?
No / ᐊᐅᑲ / Non Yes / ᐋ / Oui If yes, what is your job title and who is your employer?
Are you in charge of paying bills?
No / ᐊᐅᑲ / Non Yes / ᐋ / Oui What is your highest completed level of education?*
Elementary School (1 to 6) / ᐳᒃᑭᓂᕐᓴᖅ (1-ᒥᑦ 6-ᒧᑦ) / Primaire (1 à 6) High School (1) / ᐳᕐᑐᓂᕐᓴᖅ (1) / Secondaire (1) > (2) (3) (4) (5) Continuing Studies / ᑲᔪᓯᓂᖅ ᐃᓕᓐᓂᐊᓂᕐᒥᒃ / Études permanentes Certification / ᐃᓕᑕᕆᔭᐅᒍᑎ / Attestation College / ᐳᕐᑐᓂᕐᓴᒋᐊᓪᓚᒃ / CÉGEP University / ᐃᓕᓐᓂᐊᕕᕐᔪᐊᖅ / Université What program? ᓇᓪᓕᐊᓃᒃ ᐃᓕᓐᓂᐊᓱᑎᑦ? Dans quel programme ?
Have you ever attended a program for dependency in the past (at Isuarsivik or elsewhere)?
No / ᐊᐅᑲ / Non Yes / ᐋ / Oui If yes, which recovery centre have you been to, and can you please tell us more about the program?
Have you ever received support from any of the following services?
Alcoholic Anonymous / ᐃᒥᐊᓗᒻᒥᒃ ᓄᕐᖃᖃᔦᕐᓯᒪᔪᑦ ᑲᑎᖕᖓᓂᖓ / Alcooliques anonymes Community Workers / ᓄᓇᓕᓐᓂ ᐱᓇᓱᑦᑏᑦ / Travailleurs communautaires Social Services / ᐃᓄᓕᕆᔨᒃᑯᑦ / Services sociaux Natural Helpers / ᐃᑲᔪᕐᑎᑐᐃᓐᓀ / Aidants naturelsᑦ Other / ᐊᓯᖏᑦ / Autres
If other, please provide details: ᐊᓯᖏᑦ Si autres, détails :
We receive several applications annually and many of our guests are selected from our waiting list. If you are not accepted for the next cycle, are you willing to add your name on the waiting list?
No / ᐊᐅᑲ / Non Yes / ᐋ / Oui If No, please explain: ᐊᐅᑳᕈᕕᑦ ᑐᑭᓯᓇᕐᑎᒍᒃ Sinon, expliquez.
DEPENDENCY BACKGROUND / ᐅᐃᕆᒪᓃᑦ / HISTORIQUE DE DÉPENDANCE
What are your substances of choice (i.e. beer, marijuana, etc.)?
How often do you consume and how much at a given time (e.g. 12 beers once a week)?
Have you ever tried to reduce or stop your consumption by yourself?
Yes / ᐊᐅᑲ / Oui No / ᐋ / Non I don't have dependency issues / ᐅᐃᕆᒪᓂᕐᒥᒃ ᐱᓀᓗᑕᖃᑦᔭᖏᓪᓚᖓ
How would you rate your level of motivation to attend Isuarsivik's six-weeks individual healing program? / ᐳᕐᑐᓂᖃᕐᑎᓗᒍ 1-ᒥᑦ 5-ᒧᑦ, ᖃᓄᐃᓪᓗᐊᑐᒦᒃ ᐱᓀᓗᑕᓪᓚᕆᐅᔪᕆᕙᑎᑦ ᐅᐃᕆᒪᓂᕐᒧᑦ ᐱᓀᓗᑕᑎᑦ? / Sur une échelle de 1 à 5, dans quelle mesure êtes-vous prêt à être honnête à propos de votre consommation d'alcool ou de drogues ? (1 = slightly motivated and 5 = highly motivated) / (1 ᐱᓀᓗᑕᐅᓪᓗᐊᒐᓛᑦᑎᓇᒍ – 5 ᐱᓀᓗᑕᓪᓚᕆᐊᓘᑎᓪᓗᒍ) / (1 = « Je vais probablement minimiser le problème » et 5 = « Je suis maintenant prêt à être honnête »)
1 2 3 4 5
On a scale of 1 to 5, how serious would you say your dependency issues are?
1 2 3 4 5
On a scale of 1 to 5, how honest are you willing to be about your drinking or using?
1 2 3 4 5
How would you rate your level of motivation to attend Isuarsivik's six-weeks individual healing program? / ᐳᕐᑐᓂᖃᕐᑎᓗᒍ 1-ᒥᑦ 5-ᒧᑦ, ᖃᓄᐃᓪᓗᐊᑐᒦᒃ ᐱᓀᓗᑕᓪᓚᕆᐅᔪᕆᕙᑎᑦ ᐅᐃᕆᒪᓂᕐᒧᑦ ᐱᓀᓗᑕᑎᑦ? (1 = I'm likely to minimize the problem and 5 = I'm now ready to be fully honest) / (1 ᐱᓀᓗᑕᐅᓪᓗᐊᒐᓛᑦᑎᓇᒍ – 5 ᐱᓀᓗᑕᓪᓚᕆᐊᓘᑎᓪᓗᒍ)
1 2 3 4 5
Do you have people in your life that are there to support you in your healthy choices?
Yes / ᐊᐅᑲ / Oui No / ᐋ / Non
If yes, who? ᐊᖏᕈᕕᑦ, ᑭᓇᒃᑯᑦ? Si oui, qui?
Is your choice to attend this program mainly based on satisfying someone else's needs in your life?
No (it's my decision) / ᐊᐅᑲ (ᓇᒻᒥᓂᖅ ᑐᑭᑖᕋ) / Non (c'est ma décision) Yes (for someone) / ᐋ (ᐊᓯᒐᓄᑦ) / Oui (pour quelqu'un)
Who? / ᑭᓇᒧᑦ? / Qui ?
Given the situation you're in right now, what is your primary goal?
Quitting alcohol or drugs / ᓄᕐᖃᓂᖅ ᐃᒥᐊᓗᒻᒥᒃ ᐊᒻᒪᓗ/ᐅᕝᕙᓘᓐᓃᑦ ᐋᖓᔮᓐᓇᑐᓂᒃ / Arrêter l'alcool, les drogues Reducing my consumption / ᐱᓪᓗᐊᖃᔦᕐᓂᒥᒃ / Réduire ma consommation
SUICIDAL RISK ASSESSMENT / ᐃᒻᒥᓂᐊᑐᐃᓐᓇᕆᐊᖃᕐᓂᖓᓂᒃ ᖃᐅᔨᓴᕐᓂᖅ / ÉVALUATION DU RISQUE DE SUICIDE
Do you have suicidal thoughts?
Yes / ᐊᐅᑲ / Oui No / ᐋ / Non
On a scale of 1 to 10, where would you place yourself today? - (1 = "I don't think about suicide at all" and 10 = "constant suicidal thoughts.) ᐳᕐᑐᓂᓕᒻᒥᒃ 1-ᒥᑦ 10-ᒧᑦ, ᓇᒨᑦ ᓇᒻᒥᓂᖅ ᐃᓕᒐᔭᕐᕿᑦ ᐅᓪᓗᒥ? - (1 ᐃᒣᑦᑑᑎᓪᓗᒍ "ᐃᒻᒥᓂᐊᕈᒪᓂᕐᒥᒃ ᐃᓱᒪᓲᖑᒐᓛᖕᖏᓚᖓ" – ᐊᒻᒪᓗ 10 ᐃᒣᑦᑑᑎᓪᓗᒍ "ᑌᒪᖕᖓᓕᒫᖅ ᐃᒻᒥᓂᐊᕈᒪᓂᕐᒥᒃ ᐃᓱᒪᕗᖓ Sur une échelle de 1 à 10, où vous situeriez-vous aujourd'hui ? - (1 = « Je ne pense pas du tout au suicide » et « 10 = Pensées suicidaires constantes »)
1 2 3 4 5 6 7 8 9 10
Over the past month, have you wished you could fall asleep and never wake up?
Yes / ᐊᐅᑲ / Oui No / ᐋ / Non
Have you attempted suicide in the past?
No / ᐊᐅᑲ / Non Yes / ᐋ / Oui
If yes, how many times and how long ago? / ᐊᖏᕈᕕᑦ, ᖃᑦᓯᕕᑦᓱᑎᑦ ᐊᒻᒪᓗ ᖃᖓ? / Si oui, combien de fois et à quand remonte la plus récente ?
If you are currently experiencing suicidal thoughts, we strongly recommend that you ask for help. Please contact one of the following resources as soon as possible: emergency services, your local clinic, your referral worker, a social worker in your community, a life helpline, etc. / ᐃᒻᒥᓂᐊᕐᓂᒥᒃ ᐃᓱᒪᖃᑦᑕᑐᐊᕈᕕᑦ ᒫᓐᓇ, ᐃᑲᔪᕐᑕᐅᒍᒪᖁᔨᓪᓚᕆᒃᑯᒍᑦ. ᐅᖄᓚᒋᑦ ᐅᑯᐊ ᐊᑐᐃᓐᓇᐅᔪᑦ ᓇᓪᓕᐊᓄᑦ ᒫᓐᓇᓴᐅᑎᒋᒃ: ᐅᐃᒪᓇᕐᑐᒥᒃ ᐱᒍᑦᔨᔩᑦ, ᓄᓇᓕᑦᓯᓂ ᐋᓐᓂᐊᕕᒃ, ᐃᓱᐊᕐᓯᕕᓕᐊᖁᔨᔪᑦ ᐱᓇᓱᑦᑎᖓ, ᐃᓄᓕᕆᔨ ᓄᓇᓕᑦᓯᓂ, ᐊᑭᖃᖕᖏᑐᖅ ᐃᑲᔪᕐᑕᐅᕕᒃ ᐅᖄᓚᐅᑎᒃᑯᑦ, ᐊᓯᖏᓪᓗ. / Si vous avez actuellement des idées suicidaires, nous vous recommandons fortement d'aller chercher de l'aide immédiatement. Veuillez contacter dès que possible l'une des ressources suivantes : les services d'urgence, la clinique de votre communauté, votre travailleur de référence, un travailleur social, une ligne d'assistance téléphonique, etc.
