Intake Form

Referral Source

Referral Date

Referrer name (self or other)

Referrer source (self or other)

Applicant Release date

Email

Contact Number

If yes, please specify

Applicant Information

Date of Birth

SIN

PHN (Health #)

Family Status

Identifies as Aboriginal (Band/Metis)

Languages Spoken

What is your current housing/living situation?

Identification?

If yes, please describe the safety risks.

Allergies

If yes, how many have you had?

Dietary needs/nutritional needs?

When were you last tested for TB?

Mental Health issues (schizophrenia, bi-polar, OCD, depression, other)

Please list any medication and (dosage), including methadone/suboxone

Doctor

Dentist

Psychiatrist

Other (i.e., counsellor)

Is there anything that you need help with immediately? (Appointments, belongings, reminders, probation order, etc.)

Substance Use of Choice

Date of last use:

Previous and/or current treatment for addiction/mental health? (i.e., group therapy, individual therapy, A.A, N.A etc.) Please include therapist names, locations, and dates if possible

Barriers/Considerations (i.e. mental health/risks/no prior employment/learning disability)

Why do you think you will be a good fit for New Roads TC at this time? (i.e. strengths, values)

What do you hope to achieve through the New Roads process? (i.e. short-term and long-term goals)

Phone

This field is for validation purposes and should be left unchanged.

Referral Source

Applicant Information

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Intake Form

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