Substance Use Treatment Application Substance Use Treatment beds are available to adults (aged 19+) and youth (aged 12-18) in the Interior Health region. Please select your age from the drop down to complete the correct application: Age Please select your ageI am 12 - 18 years of ageI am 19 years of age or older You have selected the YOUTH application You have selected the ADULT application We can accept self-referrals, but it is strongly recommended that a clinician assist you with your application. Treatment Centre Information Treatment Centre Information The following treatment centres are available to individuals (12-18 years of age) who reside in the Interior Health region. Please indicate your placement preference Treatment Centre Preference youth radios No Preference, first available space Kelowna: The Bridge - Youth Recovery House Kamloops: A New Tomorrow - Youth Recovery Centre Why do you prefer this location? Treatment Centre Information Treatment Centre Information The following treatment centres are available to individuals (19 years of age and older) who reside in the Interior Health region. Please indicate your placement preference Treatment Centre Preference No Preference, first available space Kamloops: A New Tomorrow Treatment Solutions Why do you prefer this location? Information Questionnaire Legal First Name Legal Last Name Preferred Name Address City/Town - Select -OntarioAlbertaSaskatchewan Manitoba British ColumbiaNova Scotia New BrunswickNewfoundland and LabradorNorthwest TerritoriesPrince Edward Island NunavutYukonQuebec Province Postal Code? Example: A1A 1A1 Phone? Email? How do you want to be contacted? Text Email Phone OK to leave message Date of birth? Age? Personal Health Number Sex Male Female Gender Identity Pronouns Who do you live with? Parent/Legal Guardian Friend Homeless/Shelter Relative Foster Care Other (specify) Enter other… Information Questionnaire Legal First Name Legal Last Name Preferred Name Address City/Town - Select -OntarioAlbertaSaskatchewan Manitoba British ColumbiaNova Scotia New BrunswickNewfoundland and LabradorNorthwest TerritoriesPrince Edward Island NunavutYukonQuebec Province Postal Code? Example: A1A 1A1 Phone? Email? How do you want to be contacted? Text Email Phone OK to leave message Date of birth? Age? Personal Health Number Sex Male Female Gender Identity Pronouns Legal Guardian Information Legal Guardian Information Name(s) Address City/Town - Select -OntarioAlbertaSaskatchewan Manitoba British ColumbiaNova Scotia New BrunswickNewfoundland and LabradorNorthwest TerritoriesPrince Edward Island NunavutYukonQuebec Province Postal Code? Example: A1A 1A1 Phone? Email? Clinician Information Clinician Information It is strongly recommended that you are working with a mental health and substance use counselor Name Title Organization Phone? Email? Education Are you currently attending school? Yes No Date last attended School Name & District School staff contact Phone? Community Support / Groups Community Support / Groups Select all that apply Interior Health Groups (list all): Interior health groups list Select all that apply Alcoholics Anonymous SMART Recovery/ LifeRing Narcotics Anonymous Other: Other: Cultural Information Cultural Information Do you self-identify as Aboriginal Yes No Ethnicity Languages spoken We invite you to let us know if there are any spiritual, religious practices or ceremonies that will support your wellness while in treatment. We invite you to let us know if there are any spiritual, religious practices or ceremonies that will support your wellness while in treatment. Legal History Legal History Do you have any outstanding charges? Yes No If yes, please describe. Do you have any upcoming court dates? Yes No If yes, when and do you need transportation support? Are you currently on bail/probation? Yes No Legal History Legal History Do you have any outstanding charges? Yes No If yes, please describe. Do you have any upcoming court dates? Yes No If yes, when and do you need transportation support? Are you currently on bail/probation? Yes No Have you ever been convicted of a violent crime or sexual offense? Yes No If yes, please describe. Housing / Accommodation / Transportation Housing / Accommodation / Transportation Please tell us about your current and post treatment housing. Do you currently have safe housing? Yes No If no, please describe safety concerns. What is your housing plan after treatment? Please describe housing arranged for after treatment (include address, if available). What is your housing plan after treatment? Please describe housing arranged for after treatment (include address, if available). How will you travel to/from treatment? How will you travel to/from treatment? Mental and Physical Wellbeing Mental and Physical Wellbeing Do you have any disordered eating habits (i.e restricting, bingeing)? Yes No If yes, please describe. Do you have any self-injury behaviors (i.e. cutting, burning)? Yes No If yes, please describe and include most recent date. Do you have any suicidal thoughts and/or have attempted suicide? Yes No If yes, please describe. Do you have a history of verbal, physical or sexual violence towards others? Yes No If yes, please describe. Would you like family counselling during your stay? Yes No Do you have any suspected mental health conditions? (e.g. depression, Post Traumatic Stress Disorder (PTSD), anxiety) Yes No If yes, please describe. Do you have any suspected or diagnosed medical concerns? (e.g. Fetal Alcohol Syndrome Disorder (FASD), Acquired Brain Injury (ABI), seizures, kidney, liver issues) Yes No If yes, please describe. Do you have any dietary needs? Yes No If yes, please describe. Have you experienced concerns with any of the following during the PAST YEAR? Have you experienced concerns with any of the following during the PAST YEAR? Gaming Pornography Gambling Sexuality Identity Self-esteem Social media Sleep Relationships Not applicable Have you been hospitalized for any reason in the last year? Yes No If yes, please describe. Do you have any health concerns that may impact your ability to participate fully in programming? Yes No Let us know if you require specific accommodation. Mental and Physical Wellbeing element Mental and Physical Wellbeing element Do you have any disordered eating habits (i.e restricting, bingeing)? Yes No If yes, please describe. Do you have any self-injury behaviors (i.e. cutting, burning)? Yes No If yes, please describe and include most recent date. Do you have any suicidal thoughts and/or have attempted suicide? Yes No If yes, please describe. Do you have a history of verbal, physical or sexual violence towards others? Yes No If yes, please describe. Are you on any prescription medication, including Opioid Agonist Therapy (OAT)? Yes No If yes, please list. Do you have any suspected mental health conditions? (e.g. depression, Post Traumatic Stress Disorder (PTSD), anxiety) Yes No If yes, please describe. Do you have any suspected or diagnosed medical concerns? (e.g. Fetal Alcohol Syndrome Disorder (FASD), Acquired Brain Injury (ABI), seizures, kidney, liver issues) Yes No If yes, please describe. Do you have any dietary needs? Yes No If yes, please describe. Have you experienced concerns with any of the following during the PAST YEAR? Have you experienced concerns with any of the following during the PAST YEAR? Gaming Pornography Gambling Sexuality Identity Self-esteem Social media Sleep Relationships Not applicable Have you been hospitalized for any reason in the last year? Yes No If yes, please describe. Do you have any health concerns that may impact your ability to participate fully in programming? Yes No Let us know if you require specific accommodation. Substance Use and Treatment History Substance Use and Treatment History Have you ever been in a treatment program (including day programs) to get help with substance use? Yes No If yes, please provide treatment program details. Substance history row Please select a substance type from the drop down list and provide details about your substance use. Click the + button to add additional rows. Substance history row Substance Type - Select -Opioids (e.g. fentanyl)AlcoholNicotineStimulants (e.g. cocaine)Benzos (e.g. valium) Substance Method of use (smoke, IV, etc.) Amount / Quantity used when using Unit for Amount / Quantity used - Select -MillilitresLitresOuncesMilligramsGramsPointsOther Specified Unit (if Other selected) Number of days used in the last 30 days Date of last use Treatment goal (stop use, reduce harm, etc .) Item weight What else do you hope to accomplish during your time with us (school, work, family, etc.)? What else do you hope to accomplish during your time with us (school, work, family, etc.)? Circle of Care Circle of Care Please indicate additional people within your circle of care that you would like to be included in planning and supporting your care. ? Circle of care Relationship - None -Family or FriendSocial WorkerSubstance Use ClinicianMental Health WorkerFamily Support WorkerElderPhysicianBail / Probation OfficerOther (psychiatrist, psychologist, mentor, etc.) Name Organization Phone? Email? Item weight Signature Date Enter your name Signature: Signature: CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
