New Customer Registration Form

Last Door Recovery Society – 90‑day Inpatient Treatment Application
Application Period: February 1st to February 28th, 2026

Program Length: 90 days (inpatient / bed‑based)

This application is for individuals seeking admission to a 90‑day inpatient addiction treatment program at Last Door Recovery Society in New Westminster, BC. Please answer the following questions as honestly and completely as you feel comfortable. Special thanks to the Kendall Gender Foundation for supporting this cause
Eligibility Confirmation
Are you 19 years of age or older?*

YesNo
What is your current age*
Do you Identify as a male?*

YesNo
This funded treatment space is intended for anyone who identifies as male and is part of the LGBTQIA2S+ community. Does this apply to you? (This question is asked respectfully to ensure this funded space is offered as intended.)*

YesNoPrefer not to say
Contact Information
Full Name*

First NameLast Name
Phone Number *
City/Province *
Addiction/Health History
What substances or behaviors are you currently struggling with?*
How long have these challenges been part of your life?*
Are you currently on any medications? If so, please state them below *
Do you have any pending or previous criminal charges? *
Have you experienced any mental health challenges (for example: anxiety, depression, trauma, psychosis, or other concerns)?*

YesNoPrefer not to say
If yes to the above question, please briefly describe
Are you connected to any mental health support services currently?*
Have you attended addiction treatment before?*

YesNo
If yes, please share where you have been and when
If you have been to treatment in the past, what worked for you? What did not?
Do you have any physical health concerns currently? If so, can you please state them below?
Have you been hospitalized in the last 3 years? If so, why?
Motivation for Treatment
Why do you feel a 90‑day inpatient (bed‑based) treatment program is needed at this time in your life?*
What are you hoping will change in your life as a result of treatment?*
What are your goals following completion of the program? (For example: recovery goals, housing, employment, relationships, education, or community connection.)*
Program Information & Acknowledgement
Please read carefully: -Last Door is a nicotine‑free program. Support will be provided to help participants overcome their nicotine use. -Treatment focuses on drug, alcohol, and gaming addictions. -Not all applicants will be accepted. -Individuals who are shortlisted will be contacted for a screening call by the Last Door Recovery intake team. -Travel to New Westminster is not provided. -Prescribed medication costs are the responsibility of the client. Do you understand these statements?

YesNo
Last Door is a social model program, where recovery happens through peer support, written assignments, self reflection written assignments and medical guidance from an addictions physician. I am aware that I will be attending mutual support groups that include 12 step meetings. Clients participate in daily group therapy, family members are invited to participate in Last Door's family program, as well as a weekly partners group for clients partners. I have reviewed www.lastdoor.org to see what the program is and feel that is suitable for my recovery journey.

Yes, I feel that Last Door is a fit for meNo, I do not see myself taking part in these things.
Consent: I agree to have someone from Last Door Recovery Society contact me by phone at the number I have provided.

YesNo
Confidentiality Statement

All information provided in this application is protected and kept strictly confidential. Information will not be shared with anyone outside of Last Door Recovery Society, including the Kendall Gender Foundation. Applications will be reviewed only by the Last Door Recovery Society intake team.
Should be Empty:

Last Door Recovery Society – 90‑day Inpatient Treatment Application

Eligibility Confirmation

Contact Information

Addiction/Health History

Motivation for Treatment

Program Information & Acknowledgement

Confidentiality Statement