Youth Treatment Application

If you are unable to access the application below you can download it by clicking here

Admission Guidelines and Information

A New Tomorrow is not a detox or withdrawal management facility therefore, a minimum of 5 to 7 days substance free is required. Urine tox screen is collected upon Admission.

Please fill out the form below to complete your application to A New Tomorrow Treatment Centre.

2026 Youth Registration Form

Please Consent

I consent to authorized personnel at A New Tomorrow accessing my personal health information contained within PharmaNet and MediTech for the purpose of providing therapeutic treatment or care to me, or for the purpose of monitoring drug use by me.

PART A - Youth Information Questionnaire

To be completed by Participant with assistance, as needed.

Legal First Name

Legal Last Name

Preferred Name

Date of Birth

What is your age?

Personal Health Number

Sex at Birth

Male

Female

Gender Identity

Pronouns

Are you pregnant?

Yes

Do you have a fixed address?

Yes, I have a fixed address

I have no fixed address

Address

Address Line 1

Address Line 2

City

Province

Postal Code

City

Province

Phone/Mobile

If you selected other please specify here:

Legal Guardian Information

Legal Guardian 1 First Name

Legal Guardian 1 Last Name

Legal Guardian 2 First Name

Legal Guardian 2 Last Name

Legal Guardian Address

Address Line 1

Address Line 2

City

Province

Postal Code

Legal Guardian Phone/Mobile

Legal Guardian Email

Education

Are you currently attending school?

Yes

Date last attended

Cultural Information

Do you self-identify as Indigenous?

Yes

Please select

Inuit

First Nations

Metis

Please provide your Status Number (Applicable for payment and billing related to prescriptions)

I am not registered

Please select

I live on reserve

I live off reserve

Legal History

Do you have any outstanding charges?

Yes

If Yes, please describe

Are you currently on bail?

Yes

Do you give consent to contact your bail supervisor?

Yes

Please include Bail Supervisor Name and Contact Information

Are you currently on probation?

Yes

Do you give consent to contact your probation officer?

Yes

Please include Probation Officer Name and Contact Information

Do you have any upcoming court dates?

Yes

If yes, when? and can someone attend on your behalf?

Have you ever been convicted of a violent offence?

Yes

If Yes, please describe

Have you ever been convicted of a sexual offence?

Yes

If Yes, please describe

Do you have a history of engaging in sexually inappropriate, abusive, or non-consensual behaviours?

Yes

If Yes, please describe

Do you have a history of fire-starting behaviour?

Yes

If Yes, Please describe

Mental and Physical Wellbeing

If 'other' or if 'Personality Disorder', please describe:

Are you certified under the Mental Health Act?

Yes

If yes, please select expiry date

Do you have an Acquired Brain Injury (ABI) or a Traumatic Brain Inury (TBI)?

Yes

Do you have Fetal Alcohol Syndrome (FASD)?

Yes

Do you have any self-injury behaviours? (i.e. cutting, burning, purging, bingeing)

Yes

If 'yes' please describe and include most recent date

Do you have any suicidal thoughts?

Yes

If 'yes' please describe

Have you ever attempted suicide?

Yes

If 'yes' please describe

Do you have any suspected or diagnosed physical concerns? (e.g. seizures, kidney / liver issues) If yes, please describe.

Yes

If yes, please describe

Are you on Opioid Agonist Therapy (OAT)

Yes

Please describe

Have you been admitted to hospital for any reason in the last 3 months?

Yes

If yes, please describe

Do you have any allergies/dietary needs?

Yes

If yes, please describe

Do you have any barriers to completing activities of daily living (ADLs) health concerns that may impact your ability to participate fully in programming? Let us know if you require specific accommodation.

Yes

Specific Accommodations Required

Do you have any mobility issues?

Yes

If Yes, please describe mobility issues and if you require any mobility aids.

Do you have any scheduled upcoming medical appointments?

Yes

If yes, please describe

PART B - Substance Use and Treatment History Questionnaire

Please complete the section for each applicable substance(s)

Have you ever been in a treatment program (including day programs) to get help with substance use?

Yes

Please input facility and date if completed.

Opioids

Applicable

Not Applicable

Opioids

(e.g. Heroin)

Substance

Method of Use (smoke, IV, etc)

Amount/Quantity used when using

Treatment Goal (stop use, reduce harm etc.)

# of days used in the last 30 days

Date of last use

Alcohol

Applicable

Not Applicable

(e.g. Cocaine)

Substance

Method of Use (smoke, IV, etc)

Amount/Quantity used when using

Treatment Goal (stop use, reduce harm etc.)

# of days used in the last 30 days

Date of last use

Benzodiazepines

Applicable

Not Applicable

Benzodiazepines

(e.g. Valium)

Substance

Method of Use (smoke, IV, etc)

Amount/Quantity used when using

Treatment Goal (stop use, reduce harm etc.)

# of days used in the last 30 days

Date of last use

Other

Anything that doesn't fit the above categories

Substance

Method of Use (smoke, IV, etc)

Amount/Quantity used when using

Treatment Goal (stop use, reduce harm etc.)

I authorize A New Tomorrow Treatment Solutions to obtain and/or release oral and/or written information pertinent to my stay and programming at the A New Tomorrow facility.

	Yes
Physician
Emergency Contact
Social Worker
Psychologist
Psychiatrist
Counsellor
Mental Health Worker
Bail/Probation Officer
Indigenous Support Worker
Other

If you selected 'Other' please list their contact information

I understand that every effort will be made to maintain the confidential nature of the information. My consent for release of information will be in effect for the length of stay at A New Tomorrow Treatment Solutions.

I understand that I may revoke my consent at any time. I understand that confidentiality cannot be maintained under some circumstances.

Clients Name

Signature

Sign Here

Please select today's date

Participation Agreement

I understand that A New Tomorrow is an abstinence-based program and there are expectations regarding my conduct while a participant in the program. I agree to the following:

I have read and agree to the participation agreement

Submit your application

If you proceed to intake, further information will be obtained from one of our staff regarding those in your care team.

By submitting this form you agree to all the terms and conditions as stated by A New Tomorrow Treatment Solutions and that all the above information is true.

Signature

Sign Here

Ready to Apply for the program?

It's easy. Simply click the relevant button below to begin your application process.

Adult Application

Youth Application

Transition Application