Bridgepoint Center for Eating Disorders

WELCOME TO BRIDGEPOINT
CENTER FOR EATING DISORDERS

BRIDGEPOINT

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Mail To:
BRIDGEPOINT
Center for Eating Disorders
Box 190,
Milden, Saskatchewan
S0L 2L0

REFERRAL DATA BASE

BRIDGEPOINT’S INTENSIVE RETREAT FOR ADOLESCENTS, PARENTS, GUARDIANS AND FAMILY

A five (5) day Intensive Retreat at BridgePoint that offers information and exploration through a variety of program activities for ADOLESCENTS and FAMILIES of adolescents who are struggling with an eating disorder and related behaviors. Our intention is to create a safe, responsive environment for adolescents and family members to consider eating disorders as a way of coping, to share experiences and to learn. We will offer and invite ways of providing support to the individual struggling with disordered eating. If this might ‘fit’ for you, please read on …

Our residential retreat rural setting will provide you with an opportunity for gentle reflection and perhaps the chance to try living in a different way for these 5 days.

BridgePoint Center utilizes a group model of support, facilitated by experienced program team members. Activities are experiential and varied, dependent on the group and your needs. Activities are arranged in a holistic way to include group discussion(s), video presentation(s), creative expression, breathing/stretching/movement, journaling, music, body connecting, walking/outdoor leisure, peer counseling…

On the attached questionnaire you will notice that we ask you to describe your food preferences and aversions. It is important to know what food allergies you may have. Our intention is to get to know you a little better, and to help us plan meals. At BridgePoint we attempt to provide a variety of basic, wholesome, nutritious meals. We do not provide specialty foods or Diet Pop, so please plan to bring your own.

For your stay, we recommend you bring personal items, weather appropriate clothing, a journal and/or paper and a pen, and something familiar; i.e. favorite music, pillow, book, inspirational items.

If you are on any medication, prescription and/or non-prescription, please bring a sufficient supply in their original containers to last the duration of the retreat. Please note: Our village pharmacy and drug store has recently closed. Pleas ensure you bring any (for example) personal hygiene products, cough or headache remedies that you anticipate you may need.

You may refer yourself for weekend retreats by calling the Center directly. Please contact the Center to REGISTER and, send the completed referral package.

Cost: A donation is welcome. Our charitable # is 883784589RR0001

_______________________________________
Name (Last, First, Middle) of Adolescent

_____________/_____________/_____________
Date of Birth Day/Month/Year

_______________________________
SHSP Number

_________________________________________
Current Residential Address (Street)

_________________________________________
Mailing Address (If Different)

_________________________________________
City/Town, Province Postal Code

_________________________________________
Client Home Phone Number

_________________________________________
Client Work Phone Number

_________________________________________
Next of Kin/First Contact Person

_________________________________________
Address

_________________________________________
City/Town, Province Postal Code

_________________________________________
Relationship

_________________________________________
Phone Number

________________________________________
Fax Number

________________________________________
Client E-mail Address of Adolescent

FOR BRIDGEPOINT USE ONLY:

Please list all family members who will be attending; include relationship to the adolescent, gender and date of birth.

__________________________________________________________________________________________

__________________________________________________________________________________________

Questions to be completed by Adolescent Participant

Who are your support persons, including counseling?

__________________________________________________________________________________________

Please indicate your expectations for this retreat.

__________________________________________________________________________________________

Please indicate your food preferences, those foods you feel safe around. Are you vegan? Vegetarian? Also identify specific foods that cause you anxiety, and any food allergies.

__________________________________________________________________________________________

_________________________________________ Client Signature:	________________________________________ Date:

Questions to be completed by Family Participant (1)

Who are your support persons, including counseling?

__________________________________________________________________________________________

Please indicate your expectations for this retreat.

__________________________________________________________________________________________

Please indicate your food preferences, those foods you feel safe around. Are you vegan? Vegetarian? Also identify specific foods that cause you anxiety, and any food allergies.

__________________________________________________________________________________________

_________________________________________ Client Signature:	________________________________________ Date:

Questions to be completed by Family Participant (2)

Who are your support persons, including counseling?

__________________________________________________________________________________________

Please indicate your expectations for this retreat.

__________________________________________________________________________________________

Please indicate your food preferences, those foods you feel safe around. Are you vegan? Vegetarian? Also identify specific foods that cause you anxiety, and any food allergies.

__________________________________________________________________________________________

_________________________________________ Client Signature:	________________________________________ Date:

Questions to be completed by Family Participant (3)

Who are your support persons, including counseling?

__________________________________________________________________________________________

Please indicate your expectations for this retreat.

__________________________________________________________________________________________

Please indicate your food preferences, those foods you feel safe around. Are you vegan? Vegetarian? Also identify specific foods that cause you anxiety, and any food allergies.

__________________________________________________________________________________________

_________________________________________ Client Signature:	________________________________________ Date:

ACCOMMODATION ARRANGEMENTS

Adolescents will stay on site in accommodation provided. Family participants are responsible for their own accommodation, although meals will be provided on site. Please see following list of potential, available accommodations for Family participants.

ACCOMODATIONS

MILDEN

Milden Hotel 306-935-2051

GlenBridge Apartment 306-935-2240

Milden Campground (electrical hookups and sewage disposal) 306-935-2131 (or contact BridgePoint 935-2240)

OUTLOOK ½ hour drive

Bird’s Nest Inn 306-867-8661

Irrigation Centre Motel 306-867-8633

Outlook Motor Hotel 306-867-8636

Reed’s Roost Bed and Breakfast 306-867-9609

Outlook Regional Park (electrical hookups and sewage disposal)

ROSETOWN ½ hour drive

COUNTRY Rose Inn 306-882-3093

Heartland Motor Inn 306-882-4200

Rosetown Motel