Individual Registration Form

Program Centre Information

The following treatment centres are available to individuals who reside in the BC region. Please indicate your placement preference.


PART A - Client Referral Information


Legal Guardian

If no legal guardian, please input emergency contact information 


Education


Cultural Information


Legal History


Client Health & Wellness


Program Goals

Please write out the referral sources program goals for the Client


Transition and Permanency Planning

Please write out the transition and permanency plan for the Client in the space below


PART B - Substance Use and Treatment History Questionnaire


CYSN Information


Circle of Care

Please complete as applicable


Social Worker

Please provide social worker details


Therapist

Please provide Therapist details


Psychiatrist

Please provide Psychiatrist details


Family Support Worker

Please provide Family Support Worker details


Elder

Please provide Elder details


Physician

Please provide Physician details


Bail/Probation Officer

Please provide Bail/Probation Officer details


Other

Please provide details if you'd like them included in the circle of care.


Submit application

If you proceed to intake, further information will be obtained from one of our staff regarding those in your care team.