Online Application

FAMILY INFORMATION
Partner's Name (if applicable):
List all children's names, ages, and gender:
Current living situation of children. Are they with you, or have you made other arrangements?
Type of CFS order (VPA, Permanent, Temporary, Supervision):
Name of agency responsible for children in care:
Worker's name and contact info:
SUBSTANCE USE HISTORY

SUBSTANCE USE HISTORY

MEDICAL & MENTAL HEALTH
Physician or Nurse Practitioner's name and contact info:
Name:

First NameLast Name
Phone Number:
Format: (000) 000-0000.
Address:
Fax:
Email:
example@example.com
Currently pregnant? If yes, estimated due date:
Do you have any current or past medical conditions? If yes, please list, as well as any recent surgeries or hospitalizations with approximate dates.
Please list all current medications:
Please list any allergies
Please bring a thirty day supply of medications in bubble packs.
Do you experience suicidal ideation? Y/N
Have you ever attempted to take your own life? Y/N If yes please describe briefly, with age, approximate date and circumstance
List any mental health diagnoses with date, name of Physician, and location:
Hospitalization history for mental health:
History of self-harm (unrelated to substance use):

TREATMENT HISTORY
Have you attended a treatment centre before? List name(s) and date(s) of other facilities attended:
Our treatment lengths start at 30 days. There is also the option to attend for 45, 60, 90, and 120 days or longer if needed. How long do you estimate your stay will be? This can be changed as needed.
LEGAL INFORMATION
Do you have any court dates that you may have to attend ? :
PAYMENT INFORMATION
Destiny Recovery and Wellness Centre is a private facility. This means that payment is required through one of the following options: Band or Treaty coverage, third-party insurance, or private payer. Please ensure arrangements are made prior to intake. Our team is available to assist with coordinating coverage if needed.
CONSENT & SIGNATURES
I understand that I may be required to provide a "Medical Clearance for Treatment' form before entry.
I consent to Destiny Recovery and Wellness Centre staff discussing my application with my referring agent (if applicable).
Applicant's Signature:
Date:

MonthDayYear
Date
Should be Empty:

FAMILY INFORMATION