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If filling out the form on behalf of someone else, please add the resident details to the best of your knowledge.
Which Staff Member was helping you with your admission?
*
Please Select
Julia
Michelle
Martin
Timmi
Seth
How would you rate your experience with Addiction Treatment Consultants?
*
Please Select
1: Extremely Poor
2: Needs work
3: Fine
4:Alright
5: Excellent
Where did you first hear about Addiction Treatment Consultants?
*
What was the biggest deciding factor when choosing a Treatment Centre?
*
Are you filling out the form on behalf of someone else?
Please Select
Yes
No
Who will be attending Treatment?
First Name
Last Name
What is your relation to the treatment resident? Please state.
Which email address should we send any treatment related communication?
*
Information on the Person Attending Treatment Program or Resident
Resident's Name
*
First Name
Middle Name
Last Name
Resident's Date of Birth
*
-
Month
-
Day
Year
Date
Does the Resident have a valid Health Card Number?
Please Select
Yes
No
Unsure
If YES, what is the Health Card Number?
Health Card Expiry Date
-
Month
-
Day
Year
Date
Resident Phone Number
*
Please enter a valid phone number.
Resident Email
*
example@example.com
Resident Address
*
Street Address
Street Address Line 2
City
Province
Postal
If the address is outside Canada, please enter below.
Participation in Treatment
Length of Treatment Program
Please Select
30 Day: Shared Accommodation $22,000 + HST
30 Day: Private Accommodation $32,750 + HST
45 Day: Shared + 14 Day Relapse $32,400 + HST
45 Day: Private + 14 Day Relapse $47,750 + HST
60 Day: Shared + 14 Day Relapse $42,900 + HST
60 Day: Private + 14 Day Relapse $62,700 + HST
75 Day: Shared + 14 Day Relapse $53,625 + HST
75 Day: Private + 14 Day Relapse $78,375 + HST
90 Day: Shared + 14 Day Relapse $63,900 + HST
90 Day: Private + 14 Day Relapse $92,700 + HST
120 Day: Shared + 14 Day Relapse $84,950 + HST
120 Day: Private + 14 Day Relapse $123,000 + HST
Is the resident willing to do treatment?
Please Select
Yes
No
Not Sure yet
It changes
Do you require a Professional Interventionist Service from Addiction Treatment Consultants, for an additional fee?
Please Select
Yes
No
I would like a quote
Family Guided Intervention Assistance
Would welcome some advice
Would the Resident require transportation by Transport service for an additional fee from within Ontario?
Please Select
Yes
No
I would like a quote
Emergency Contact Information
Emergency Contact
First Name
Last Name
Relation to Resident
Emergency Contact Email
example@example.com
Emergency Contact Phone Number
Please enter a valid phone number.
COVID-19
Has the resident knowingly been in contact with anyone who has tested positive for COVID-19 in the last 14 days?
Please Select
Yes
No
Unsure
Has the resident traveled internationally within the last month?
Please Select
Yes
No
Unsure
If YES, please indicate which countries the resident has visited.
Is the resident currently experiencing any of the following symptoms?
SORE THROAT
FEVER
COUGH
DIFFICULTY BREATHING
Legal Information
Does the resident have any current legal charges?
Please Select
Yes
No
If YES, Please state charges
Does resident have any history of violent behaviour?
Please Select
Yes
No
Does resident have any court appearances scheduled while in treatment?
If YES, what date and time is the appearance scheduled for?
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Is the court appearance in person or via Zoom link?
Please Select
In person
Zoom Link
Lawyer can attend on behalf
Addiction
Which substance(s) are being used? (DOC: Drug(s) Of Choice) : Please click all that apply.
Alcohol
Opioids
Methadone
Cocaine
Crack
Crystal Meth
Ketamine
Marijuana
Other Stimulants (Adderall, Ritalin, Vyvanse, "Speed", Concerta)
Benzodiazepines (Diazepam, Valium, Lorazepam, Ativan, Clonazepam, Xanax)
Other
How frequently is the resident using?
Please Select
Hourly
Daily
Socially
Weekly
Monthly
To excess
Binge Usage
Unsure
Does resident need to see a Physician on day of Admission?
Please Select
Yes
No
Unsure
Likely
Does the resident take or require any prescribed mood stabilizing medication?
Does the resident take any prescription medications for mental health related diagnosis? If YES, please list.
Does resident have any health related issues OUTSIDE of their addiction? If YES, please explain.
Does resident have any health conditions as a DIRECT result of their addiction? If YES, please explain.
Does the Resident have a history of seizures from withdrawal?
Please Select
Yes
No
Unsure
Has the resident tried to quit "using" prior to this? Please provide the length of time they were able to successfully stop.
Mental Health
Does resident have any mental health related diagnosis?
Please Select
Yes
No
Unsure
I believe so
If YES, please explain. (Depression, Anxiety, Bipolar etc)
Has the resident ever exhibited self-harming behaviour?
Please Select
Yes
No
Unsure
Likely
Has the resident experienced any major traumatic event(s) that we should be made aware of? If YES, please explain.
General Health
Any mobility issues? (Wheelchair, Walker, cane etc"
Has the resident ever experience a brain injury?
Please Select
Yes
No
Unsure
Are there any allergies to food or medication? If YES, please list.
Any other medical related information that we should be aware of? If YES, explain.
Information on the Client, or the person paying for treatment
Client "Payor"
First Name
Last Name
Relation to the Resident
Client Phone Number
Please enter a valid phone number.
Client Email Address (for the Client Service Agreement)
example@example.com
Client Address
Street Address
Street Address Line 2
City
Province
Postal Code
If outside of Canada, please provide address.
Payment Information for the $3000.00 Deposit
Type of Credit Card
Please Select
VISA
Mastercard
American Express
Other
If you chose "Other", please specify.
Billing Address
Street Address
Street Address Line 2
City
Province
Postal Code
Acknowledgement that balance of Payment in FULL is due upon Admission
Please Select
Yes
No
How will you be paying the balance on day of arrival?
Credit Card
Bank Draft
Electronic Fund Transfer
Personal Cheque
Other
If you chose "other", please specify.
Treatment Program
What is your preferred Arrival date and time?
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
I have been informed that Residents should be driven to the Centre by someone else?
Yes
No
I have been informed that Resident vehicles are not permitted to be parked on the Centre premises and will be towed at the owner's expense?
Yes
No
I have been advised that arriving under the influence of substances may result in delayed, or possible refusal of admission?
Yes
No
Is there any additional information that we should be aware of?
The person who researched treatment options belongs to the following age demographic
18-24 yrs
25-34 yrs
35-44 yrs
45-64 yrs
65-80 yrs
80 yrs +
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