REFERRAL INFORMATION
Referring Workers Name:
*
Referring Workers Phone Number:
*
Format: (000) 000-0000.
Referring Workers Agency:
*
Referring Workers Address:
*
Referring Workers Email:
*
example@example.com
PERSONAL INFORMATION
Applicant Full Legal Name:
*
Applicant Preferred Name:
*
Applicant Date of Birth (MM/DD/YYYY):
*
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Month
-
Day
Year
Date
Applicant PHIN # (9-digit):
*
Applicant Email:
*
example@example.com
Applicant Phone Number:
*
Format: (000) 000-0000.
Applicant Address:
*
Applicant Treaty Number: (if applicable)
*
Applicant Indigenous Band:
*
Applicant Pronouns:
*
Applicant Languages Spoken:
*
Applicant Gender Identity:
*
Applicant Marital Status:
*
Applicant Employment History (list most recent positions and dates):
*
EMERGENCY CONTACT
Emergency Contact Name:
*
Phone Number:
*
Format: (000) 000-0000.
Relationship to Applicant:
*
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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
*
Rows
Drug Type
When did you start use?
Average dose per use:
How often:
Last use date:
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3
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5
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7
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9
10
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13
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MEDICAL & MENTAL HEALTH
Physician or Nurse Practitioner's name and contact info:
Name:
First Name
Last 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:
*
Any Allergies?
*
Please attempt to bring a two-week supply of medications in their original packages.
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):
*
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TREATMENT HISTORY
Have you attended a treatment centre before? List name(s) and date(s) of other facilities attended:
*
Our treatment lengths starts 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 a criminal record? If so please list details:
*
PAYMENT INFORMATION
Destiny Recovery & 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 & Wellness Centre staff discussing my application with my referring agent (if applicable).
Applicant's Signature:
*
Date:
*
-
Month
-
Day
Year
Date
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