Client Admission Form

Please take a moment to fill out the form below

To assist in your intake process, we require our patients to complete this form. We collect information that provides a deeper insight into your history and helps us tailor the goals of your program for your best possible results. Once you submit this form, we will contact you with information for the next step in treatment.

Client (Patient) Information:
First Name*
Last Name*
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone Number
Cell Phone Number
Other Phone Number
Email Address*
Age
Gender*
- Male
- Other
- Prefer not to say
Date of Birth*
Provincial Health Care Number*
Extended Health Care Number
Extended Health Carrier
Group Plan No. (Back of Card)
Request Admission Date
Funding Guarantor (if different from client)
Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Home Phone Number
Work Phone Number
Email
Relationship to Client
- Self-Pay
- EAP
- Employer
- Family Member
- Other
Source of Information

(if different from client or Funding Guarantor)
Name of Person Completing This Application
Relationship to Client
Home Phone Number
Work Phone Number
Cell Phone Number

Save and Continue Later

Psychological History

(Emotional/Behavioral)
Are You Currently Seeing a Psychiatrist?*
- Yes
- No
Name of Psychiatrist
Are You Currently Seeing a Psychologist?*
- Yes
- No
Are You Currently Seeing a Counsellor?*
- Yes
- No
Name of Professionals
Address
Street Address City State / Province / Region ZIP / Postal Code
Office Phone Number
Have You Had Any Psychological/ Emotional Problems In The Past Two Years?*
- Yes
- No
If Yes, Please Describe
Alcohol/Drug History

Complete for alcohol or any other addictive substances you have used (including nicotine) in the past 6 months.
Name Of Drug
Pattern Of Use (Daily, Weekend, Binge)
Amount Used Per Occasion
Length Of Use
Date Of Last Use
Name Of Drug
Pattern Of Use (Daily, Weekend, Binge)
Amount Used Per Occasion
Length Of Use
Date Of Last Use
Name Of Drug
Pattern Of Use (Daily, Weekend, Binge)
Amount Used Per Occasion
Length Of Use
Date Of Last Use
Name Of Drug
Pattern Of Use (Daily, Weekend, Binge)
Amount Used Per Occasion
Length Of Use
Date Of Last Use

Save and Continue Later

Client Admission Form

Please take a moment to fill out the form below

Client Admission Form

Client (Patient) Information:

Funding Guarantor (if different from client)

Source of Information

Referring Professional

Precipitating Event/Motivation

Medical History

Psychological History

Alcohol/Drug History

Treatment History

Family

Employment Status

Legal History

Nutrition

Recovery