Referral Source *

Self

Other

Name of Person Completing This Form *

First Name

Last Name

Name of Applicant *

First Name

Last Name

Address of Applicant

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Can we leave a message on this phone?

Yes

No

Cellphone

(###)

###

####

Can we leave a message on this phone?

Yes

No

Date of Birth *

MM

DD

YYYY

Sex Assigned at Birth *

Female

Male

Intersex

Gender Identity *

Woman

Man

Non-Binary/Third Gender

Prefer to Self-Describe

Income Source *

Employed Full-Time

Employed Part-Time

Employment Insurance

Social Assistance

No Source of Income

Retired

Disablity

Other

Are you currently taking prescription medications for physical or mental health reasons? *

Yes

No

Have you ever overdosed (accidentally or otherwise)? *

Yes

No

Not Applicable

What other addictive behaviours do you currently struggle with or have struggled with? *

Check all that apply.

Gambling

Over-Spending

Internet

Food

Sex/Pornography

None

Other

Are self-help groups part of your recovery program? *

Examples: Alcoholics Anonymous, Narcotics Anonymous, SMART, etc.

Yes

No

Not applicable

Do you have any legal/criminal charges pending? *

Yes

No

Do you have any outstanding warrants? *

Yes

No

Are you currently subject to any restraining orders? *

Yes

No

Do you have any pending court dates? *

Yes

No

Are you on parole/probation with conditions? *

Yes

No