Date of Birth:*
Marital Status:*
Where are you Located?*
OK to call back?
How did you hear about us?
Is this your first call to us?*
Care Card #.
Are you currently employed?*
If no, when did you last work?
Company name?
Have you been to treatment before?
If Yes, list treatment centres and dates.
What event(s) caused you to seek treatment (this time if previous attempts)?
What substance do you use most often?
Pattern of use i.e. binge/daily :
Amount per occasion:
How long have you used this substance?
Date this substance last used?
Other substance(s) used:
Pattern of use i.e. binge/daily:
Amount per occasion :
How long have you used this/these substance(s)?
Date this/these substance(s) last used? :
Do you have any special needs such as difficulty climbing stairs, wheelchair etc.?
If Yes, Describe Below
Do you have any allergies?
If yes, list all known allergies below

List all prescribed drugs and over-the-counter drugs, such as vitamins and supplements that you are currently taking

Drug Name, Reason and Daily Dose:

Psychiatric History

Do you suffer from any eating disorders?
If yes, what specifically?
Do you self-harm?
If yes, what specifically ?
Are you currently under the care of a Psychiatrist?
Ever treated for bi-polar, schizophrenia or psychosis?
Are you now, or have you ever been suicidal?
Have you ever been admitted to a psychiatric ward?
If yes, when? For what?
Have you ever had any seizures (alcoholic or other)? If yes, describe below
Are you on probation or parole? If yes, for what offense?:
Do you have any pending appointments or commitments that may interfere with treatment? If yes, describe below
Is there anything else you feel we should know?

Orientation Handbook

Please read the attached orientation handbook and sign below acknowledging that you have read and understand the policies, philosophy, your rights and responsibilities, fees and structure of the Centre. *if you have any questions or require clarification on any of the information contained in the handbook, please contact Norma Jean 778-389-1002 or Donna 604-809-1462 before signing.

Orientation handbook

I have read the orientation handbook and I understand the policies, philosophy, my rights and responsibilities, fees and structure of the Centre.
Date :*
Print Name:*
I have read and understand the information contained in the orientation handbook.*
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