Individual Application Form - Active Care Services

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.

Program Need

CYSN

Mental Health and Substance Use

Adult Clientized Program Request

Other

If you selected other please input here

Region

Northern BC (Terrace)

Interior BC (Kamloops, Kelowna, Vernon, and surrounding areas)

Other

Preferred Program Start Date

PART A - Client Referral Information

Legal First Name

Legal Last Name

Preferred Name

Date of Birth

PHN

Sex at Birth

Male

Female

Gender Identity

Pronouns

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Phone/Mobile

How does the client want to be contacted?

Phone

(OK, to leave message)

Text

If you selected 'Parent/Family' or 'Other' please specify here:

Legal Guardian

If no legal guardian, please input emergency contact information

Legal Guardian 1 First Name

Legal Guardian 1 Last Name

Legal Guardian 2 First Name

Legal Guardian 2 Last Name

Legal Guardian Address

Address Line 1

Address Line 2

City

Province

Postal Code

Legal Guardian Phone/Mobile

Legal Guardian Email

Education

Is the client currently attending school?

Yes

Date last attended

School Name & District

School Staff Contact

Phone/Mobile

Cultural Information

Does the client self-identify as Indigenous?

Yes

Ethnicity

Languages Spoken

Legal History

Does the client have any outstanding charges?

Yes

If Yes, please describe

Does the client have any upcoming court dates?

Yes

If yes, please describe

Is the Client currently on bail/probation?

Yes

If yes, please attach copy of bail/probation order. You can upload 1 document at a max size of 4mb. Document types supported include PDF, doc, docx, txt.

Click Here To Upload

Client Health & Wellness

If you answered yes to any of the above, or 'other', please describe

Is the Client currently in the process of being assessed for any mental health diagnosis?

Yes

If yes, please describe

Does the Client engage in self harm? (i.e. cutting, burning)

Yes

If 'yes' please describe and include most recent date

Is the Client Pregnant?

Yes

If 'yes' please provide details

Does the Client have any suicidal thoughts and/or has previously attempted suicide?

Yes

If 'yes' please describe

Does the Client have a history of aggression or anger toward property?

Yes

If yes, please describe

Does the Client experience aggression or anger toward others or history of harming others?

Yes

If yes, please describe

Does the Client have a history of aggression or violence towards animals?

Yes

If yes, please describe

Does the Client have any dietary needs?

Yes

If yes, please describe

Have the Client been hospitalized for any reason in the last year?

Yes

If yes, please describe

Does the client have any health concerns we need to be aware of? Does the client require specific accommodations?

Yes

If yes, please provide details

Program Goals

Please write out the referral sources program goals for the Client

Program Goals

Transition and Permanency Planning

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

Transition Plan

PART B - Substance Use and Treatment History Questionnaire

Has the Client ever been in a treatment program (including day programs) to get help with substance use?

Yes

If Other, please describe

CYSN Information

Other Phone/Mobile

Other Email

Submit application

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