Problem Gambling
Day Treatment Program
Information and Referral Package
(Revised November 2011)
Dear Colleagues and Clients: Thank you for your interest in the ADAPT Problem Gambling Day Treatment Program. This 5-day program runs Monday through Friday, 9:30am to 3:30pm. It is available to any resident of Ontario. Our program is facilitated by professional counsellors, who specialize in the treatment of problem gambling. Funded by the Ontario Ministry and Health and Long-Term Care, all services are fully confidential and provided at no fee to the participant. We encourage participation in the program for individuals who are. . .  Beginning treatment for problem gambling and would like to establish a solid foundation for ongoing  Beginning treatment for problem gambling and would like to stabilize the gambling by accessing a full  Trying to reduce or stop his/her gambling and are struggling to meet those goals through  Working to stop or reduce gambling, but have had a relapse and would like to intensify recovery efforts.  Attending other programs and would like to learn and apply new skills and strategies that will further  wanting to attend a gambling recovery program in his/her local community, but does not feel safe in doing so because of concerned about privacy/anonymity.  Wanting to attend a residential recovery program, specific to gambling, but cannot afford more than a
The ADAPT Problem Gambling Day Treatment Program also offers a “Family and Friends” workshop for
those close to the problem gambler to gain information, education and support. Information will be provided
during the day treatment cycle.
We thank you for your interest in this program. Please do not hesitate to call our toll free Intake Line for
enquiries or referrals. The number to call is 1-866-783-7073. We look forward to hearing from you.
Kristyn Inglis
Manager, Problem Gambling Services
Referral Requirements
In order for our program to deliver the best services possible to each client, we ask that the following
information be included at the time of the referral. If possible, our staff will develop specialized programming,
based on the needs of the participants. Your assistance in helping us to have a clear
understanding of the client’s needs, goals and challenges is instrumental in enabling the program to best meet
the client’s needs.
Please include the following documents with your referral:

1) CATALYST Client Profile and Admission Information OR ADAPT Client Information form (provided
2) CATALYST OSAB Required Gambling Data Form OR OSAB form (provided in this package)
3) A signed consent to release and disclose information between referring agency and ADAPT (included in
4) A signed consent to allow the ADAPT Day Treatment Program to contact the client directly (included in 5) Safety and Special Needs form (included in this package) 6) A copy of your agency’s assessment summary for this client. Completed packages can be sent by any of the options below.
ADAPT Problem Gambling Day Treatment Program Should you have questions, please contact Kristyn Inglis at 1-866-783-7073 (toll free).
Consent to the Collection, Use and Disclosure
of Personal Health Information
Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA)

All employees of ADAPT are mandated, under law, to protect the personal health information/clinical records of every
client. Signing this form will allow consent for the sharing/disclosure of your personal health information between the
parties noted. This consent/authorization may be withdrawn, upon request, at any time.
I __________________________________________________, (D.O.B________________), of

______________________________________________________________, hereby authorize

To disclose personal health
Name of Person/Agency Disclosing Information
Information to
Name of Person/Agency Receiving Information
This consent applies to information in the records of:
_________________________________ _________________________________
Client Name (Printed) Date of Birth (dd/mm/yy)
_________________________________ _________________________________
Client Signature Today’s Date
Signature of Witness

NOTES: This section includes any explicit restrictions/instructions pertaining to the information to be
disclosed under this consent.
Problem Gambling Day Treatment Program Referral, Participation and Discharge Planning.

Consent for ADAPT to Contact
Program Participant Directly

I __________________________________________________, (D.O.B________________),

Hereby authorize ADAPT to contact me directly with the following restrictions:
Phone Contact:

Do not contact me by phone.
Contact me at the following phone numbers only: _____________________________
Never leave a phone message.
Leave a phone message, and identify ADAPT in the message.
Leave a phone message, but do not identify ADAPT in the message. Leave your name only.
Leave a phone message, but do not identify ADAPT. Identify yourself as _______________.
Contact by mail:
Do not send anything to me by mail.
Send mail to the following address:

This consent applies to information in the records of:
_________________________________ _________________________________
Client Name (Printed) Date of Birth (dd/mm/yy)
_________________________________ _________________________________
Client Signature Today’s Date
Signature of Witness


ADAPT Problem Gambling Day Treatment Program
Safety and Special Needs
It is important that your participation in the ADAPT Problem Gambling Day Treatment Program is a
safe and enjoyable experience. Please assist us in ensuring your safety and comfort by completing the
following form.
Are you presently taking medications to be taken in case of emergency? (E.g. Asthma
medications, ‘epi-pens’, Nitro-Glycerin etc)?

Please list any emergency medications you may require and will have with you during the program.



Do you have any food allergies and/or have a restricted diet due to personal, religious or medical

Please list any food restrictions you have.



ADAPT Client Information Form
Last Name at Birth:
Client Type (A D G):
Adult/ Youth/ Family Member
Referring Source:
Referring Agency:
Postal Code:
Country of Res:
Address Effective Date:
Home Phone:
ADAPT name?
Work Phone:
ADAPT name?
Cell Phone
ADAPT name?
Family Contact:
ADAPT name?
Notes/ Substance Used:
Client Number:
Client Information
In order to provide the best possible care, we ask that you complete the following questions. Client type:
What is your current relationship status?
Issues concerning:
What is your current employment status?
Are you required to attend? If yes please indicate.
What is the highest level of education completed?
What is your current legal status?
What is your current income source?
Please check any boxes that apply at this time. Presenting Issues at Admission:
Client Number:
Substance Use History
Using the list below, please list presenting problem substances and frequency of use within the PAST 30 DAYS. Presenting Problem Substance(s)
Frequency of Use (Within Last 30 Days) - Use Letter Code
Letter Codes
Please check the substances you have used within the PAST 12 MONTHS. Substances Used in Last 12 Months: (Check all that apply)
Cannabis (i.e.: Marijuana, Hash, Hash Oil) Glue/ Inhalants (i.e.: Glue, Gas, Ether, Nail Polish etc…) Other Psychoactive (i.e.: Anti-Depressants, Anti-Psychotics, Dilantin, Prozac, Lithium, Tranquilizers, Robaxin, Sleeping Pills, Zoloft etc…) Amphetamines/ Stimulants ( i.e.: Speed, Ritlan, Wake-Ups, Pseudoephedrine) Barbiturates (i.e.: Downers, Florinal, Seconal, Tuinal etc…) Benzodiazepines (i.e.: Ativan, Clonazepam, Diazepam, Valium, Xanax) Hallucinogens (i.e.: LSD, Angel Dust, MAgis Mushrooms, Mescaline, Salvia, GHB, Ketamine) Gambling History
Gambling identified as a problem?
Refer to Gambling Counsellor?
Y/ N/ Unknown
Y/ N/ Unknown
Please check the activities you have participated in within the PAST 12 MONTHS. Gambling Activities in the Last 12 Months : (Check all boxes that apply)
Gambling with Stock Market/ Real Estate Client Number:
Physical Health Status
Visual Impairment:
Hearing Impairment:
Mobility/ Physical Impairment:
Have you ever injected drugs?
Prior to one year ago
Within 12 months
Have you been admitted to the hospital overnight within the
past 12 month for a physical ailment?

Mental Health Status
Have you been diagnosed with mental health problems?
Within last 12 months
Diagnosis #1
In your lifetime
Diagnosis #2
Have you been hospitalized for mental health problems?
Last 12 months
Have you received counseling/ support/testing for mental
/emotional/ behavioral/ psychological problems?
Last 12 months
Have you received prescribed medication(s) for mental
health problems?

Prescription #1
Last 12 months
Prescription #2
Other health conditions? (e.g.: Diabetes etc…)
If yes, please list:
Family Doctor:
Methadone/ Opioid Substitute Prescribed?
Problem Gambling Day Treatment Program
Referral Package

1. Are you seeking help for:
___ your own difficulties related to a family member/significant other’s gambling. STOP HERE ___ your own gambling problem. PLEASE CONTINUE ___ both. PLEASE CONTINUE
2. Looking back now, for how many years has your gambling affected your life in negative ways?

3. Please indicate how long it has been since you last gambled:

4. Please indicate whether:

___ you came to this agency specifically for gambling treatment ___ your gambling problem surfaced in the course of other treatment Problem Gambling Day Treatment Program
Referral Package

5(a). Please indicate how often you engaged in each of the following gambling activities in the past 12
Did not gamble in the past 12 months:

5 (b). Please indicate the top three types of gambling problems, using the activity members in 5 (a):

Major ____ 1st other ____ 2nd other ____ Problem Gambling Day Treatment Program
Referral Package

6 (a). Please indicate how often you gambled in each of the following locations in the last 12 months:

6 (b). Please indicate the top three locations for gambling, using the numbers in question 6(a):

Major ____ 1st other ____ 2nd other ____
7. Thinking about the times you gambled in the past 12 months, what percent were: (numbers should
add up to 100%, zeros not necessary)

(a) in Ontario ____ % (b) In another province ____% (c) Outside of Canada ____% Problem Gambling Day Treatment Program
Referral Package
Important Information for Program Participants

Dear Program Participant:
Thank you for your interest in the ADAPT Problem Gambling Day Treatment Program. Our staff
looks forward to meeting you and to working with you. We are committed to ensuring the program
provides a safe and supportive environment for all participants. Please review this document. It
contains some key information to help you prepare for participation in the program. If you have any
questions or concerns, please do not hesitate to call the Program Manager at 905-691-0231 or toll
free at 1-866-783-7073.

Food and Refreshments:
Our program believes that good nutrition is important to a healthy lifestyle. We encourage all
program participants to eat a healthy breakfast each day before coming to the program. The
program will provide coffee, tea and snacks each morning and these will remain available
throughout the day.
Lunch will be served at noon each day. All snacks and lunch are provided at no cost to the
Food Allergies / Restrictions:
Program participants will be screened for food allergies and/or food restrictions based on medical,
religious or personal needs. We will do everything possible to ensure that the food provided
contains no ingredients identified as causing concern. Despite such precautions, some participants
may choose to provide their own lunch and/or snacks. We ask that you please inform the program
staff if you plan to bring food to the program site, to ensure that no products are brought into the site
that may cause risk to other participants.
Clothing and Dress Code:
It is important that you are comfortable during the program. We recommend that participants wear a
sweater or jacket to ensure that they can be comfortable if the room temperature fluctuates.
Please do not wear any clothing with beer/alcohol logos, drug references, or gambling references or
Participants who are taking medications for physical or mental health issues may continue to use
these medications, as prescribed, during the program. It is the responsibility of each participant to
ensure that they have all of their required medications for the day.
Under no circumstances should a participant accept or distribute medications from or to other
If recent changes in your medications are causing notable issues with lethargy or concentration,
please contact the program manager to discuss these concerns prior to the program start date.
If you have any emergency medications (‘epi-pens’, nitro-glycerin etc.), please bring these with you,
and inform the program staff of any special instructions related to the use of these medications.

Alcohol and Illicit Drug Use
During the five days of the program, all participants are asked to abstain from all alcohol and/or illicit
drug use, or overuse/abuse of prescription medications. If you feel this will be a difficult condition for
you to meet, please contact the program manager to discuss the issue prior to the program start
Problem Gambling Day Treatment Program
Referral Package

Gambling while in Program:
All program participants are encouraged to abstain from ALL forms of gambling during the course of
the program. Even where abstinence may not be your long-term goal, we ask that abstain during
the program week in order to stay focused on the program material that is provided.

Perfumes and Fragrances:
Some participants are sensitive or allergic to certain perfumes and fragrances. We ask that all
participants refrain from the use of perfumes and fragrances during the program.

Sharing Personal Information:
We strongly recommend that you do not share personal contact information (i.e. phone numbers,
addressed, e-mail addresses, etc.) with other program participants. Many models of treatment
encourage group members to share their contact information in the hope that they can provide or
gain support. In early recovery, however, the sharing of such information can increase your levels
of personal stress and anxiety. In some cases, the sharing of personal contact information can
increase relapse risk and threaten recovery.

The program does not provide transportation to and from the treatment site. All participants are
responsible for arranging their own transportation. We strongly recommend that participants do not
offer to provide transportation to other program participants. This recommendation is made for your
own protection from potential liability and/or lawsuits.
Health Card:
The program does NOT require your Health Card Number. However, we ask that all participants
have their Health Card with them at all times, in case of a medical emergency or accident that
requires services through the local hospital.
Other Special Needs:
Please inform our staff if you have any other special needs. This will help to ensure that your
involvement in the program is safe and comfortable.
Thank you for your consideration of these guidelines. We look forward to working with you
in a safe, healthy and mutually respectful environment.

Source: http://haltonadapt-org.factorepreview.ca/system/attachments/55/original/Day_Treatment_Referral_package.pdf

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