Youth Registration Form With Steps

Treatment Centre Information

The following treatment centres are available to youth who reside in the Interior Health region. Please indicate your placement preference.


PART A - Youth Information Questionnaire

To be completed by Participant with assistance, as needed.


Legal Guardian Information


Education


Cultural Information


Legal History


Housing / Accomodation


Mental and Physical Wellbeing


PART B - Substance Use and Treatment History Questionnaire


Opioids

(e.g. Heroin)


Alcohol


Nicotine


Stimulants

(e.g. Cocaine)


Benzodiazepines

(e.g. Valium)


Other

Anything that doesn't fit the above categories


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 your social worker details if you'd like them included in your circle of care.


Counsellor

Please provide your Counsellor details if you'd like them included in your circle of care.


Mental Health Worker

Please provide your Mental Health Worker details if you'd like them included in your circle of care.


Family Support Worker

Please provide your Family Support Worker details if you'd like them included in your circle of care.


Elder

Please provide your Elder details if you'd like them included in your circle of care.


Physician

Please provide your Physician details if you'd like them included in your circle of care.


Parole Officer, Probation Officer, Bail Supervisor

Please provide your Parole Officer, Probation Officer, Bail Supervisor details if you'd like them included in your circle of care.


Other (psychiatrist, psychologist, mentor etc.)

Please provide details if you'd like them included in your circle of 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.