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 


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


Please provide Therapist details


Please provide Psychiatrist details

Family Support Worker

Please provide Family Support Worker details


Please provide Elder details


Please provide Physician details

Bail/Probation Officer

Please provide Bail/Probation Officer details


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.