Adult Registration Form PART A - Information Questionnaire To be completed by Participant with assistance, as needed.
How do you want to be contacted?
Highest level of education achieved
Are you currently attending school?
Do you self-identify as Indigenous?
Do you have any outstanding charges?
Have you ever been convicted of a violent offence?
Have you ever been convicted of a sexual offence?
Do you have any upcoming court dates?
Are you currently on bail/probation?
Do you currently have safe housing?
If yes, please describe housing arranged for after treatment (include address if available). If no, please describe safety concerns and if you have any open housing applications.
Are you planning on bringing a motor vehicle to the treatment centre? If yes, please be advised there is a private parking lot for residents. Contact us for more information
Do you have any scheduled upcoming medical appointments?
If yes, please provide more information
Are you currently homeless?
If yes, please describe situation.
How will you travel home? Is assistance needed with travel to/from treatment?
Mental and Physical Wellbeing
Have you received a Psychiatric Diagnosis for:
If 'other' or if 'Personality Disorder', please describe:
Do you have an Acquired Brain Injury (ABI)?
Do you have any suspected mental health conditions
Do you have any self-injury behaviours? (i.e. cutting, burning)
Do you have any suicidal thoughts and/or have attempted suicide?
Do you experience aggression or anger toward others or history of harming others?
Would you like family counselling during your stay?
Do you have any suspected or diagnosed physical concerns? (e.g. seizures, kidney / liver issues) If yes, please describe.
Do you have any dietary needs?
Have you experienced concerns with any of the following during the PAST YEAR? If yes, select all that apply.
Have you been hospitalized for any reason in the last year?
Do you have any health concerns that may impact your ability to participate fully in programming? Let us know if you require specific accommodation.
Specific Accomodations Required
Do you have any mobility issues?
If Yes, please describe mobility issues and if you require any mobility aids.
Are you certified under the Mental Health Act?
PART B - Substance Use and Treatment History Questionnaire Please provide as much detail regarding your substance use history below
Have you ever been in a treatment program (including day programs) to get help with substance use?
Do you require assistance coordinating withdrawal management services?
Have you ever experienced any adverse side effects during withdrawal? (i.e. seizures, delirium)
Opioids (e.g. Heroin) Please provide as much detail regarding your substance use history below.
Treatment Goal (stop use, reduce harm etc.)
Alcohol Please provide as much detail regarding your substance use history below
Treatment Goal (stop use, reduce harm etc.)
Nicotine Please provide as much detail regarding your substance use history below
Treatment Goal (stop use, reduce harm etc.)
Stimulants (e.g. Cocaine) Please provide as much detail regarding your substance use history below
Treatment Goal (stop use, reduce harm etc.)
Benzos (e.g. Valium) Please provide as much detail regarding your substance use history below
Treatment Goal (stop use, reduce harm etc.)
Other Anything that doesn't fit the above categories. Please provide as much detail regarding your substance use history below
Treatment Goal (stop use, reduce harm etc.)
What else do you hope to accomplish during your time in treatment?
Circle of Care Please indicate additional people within your circle of care that you would like to be included in planning and supporting your care.
Social Worker Please provide social worker details if you'd like them included in planning and supporting your care.
Counsellor Please provide Counsellor details if you'd like them included in planning and supporting your care.
Mental Health Worker Please provide Mental Health Worker details if you'd like them included in planning and supporting your care.
Family/Friend Please provide Family/Friend details if you'd like them included in planning and supporting your care.
Elder Please provide Elder details if you'd like them included in planning and supporting your care.
Physician Please provide Physician details if you'd like them included in planning and supporting your care.
Bail/Probation Officer Please provide Bail/Probation Officer details if you'd like them included in planning and supporting your care.
Other (psychiatrist, psychologist, mentor etc.) Please provide details if you'd like them included in planning and supporting your care.
Submit your application If you proceed to intake, further information will be obtained from one of our staff regarding those in your care team.
Submit Application
