Program Centre Information

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


PART A - Information Questionnaire for Individual

To be completed as needed.


Legal Guardian Information

If no legal guardian, please input emergency contact information 


Education


Cultural Information


Legal History


Housing / Accomodation


Mental and Physical Wellbeing


Program Goals

Please write out the program goals for the individual in the space below


Transition and Permanence Planning

Please write out the transition and permanence plan for the individual in the space below


PART B - Substance Use and Treatment History Questionnaire


Opioids

(e.g. Heroin)


Alcohol


Nicotine


Stimulants

(e.g. Cocaine)


Benzos

(e.g. Valium)


Other

Anything that doesn't fit the above categories


Circle of Care

Please complete as applicable


Social Worker

Please provide social worker details


Counsellor

Please provide Counsellor details


Mental Health Worker

Please provide Mental Health Worker 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 (psychiatrist, psychologist, mentor etc.)

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.


crossmenu