Intake Online Form Intake Form Date Date Format: MM slash DD slash YYYY Name of Applicant* First Last Name of person completing this form* First Last Relationship to Applicant*Applicant InformationHome Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone*Home Phone Messages OK?*YesNoCell PhoneCell Phone Messages OK?*YesNoOther PhoneOther Phone Messages OK?*YesNoDate of Birth* Date Format: MM slash DD slash YYYY Sex Assigned at birth*FemaleMaleIntersexPrefer not to sayWhat gender do you identify as?*WomanManNon-binary/third genderPrefer to self-describePrefer not to sayPrefer to self-describePreferred Pronoun*HeSheTheyZeA pronoun not listedNo pronoun preferenceReferral SourceReferral SourceSelfOtherReferral source other (Name and Organization)How did you/they hear about Tamarack? (website; radio; newspaper; organization; family member)Employment Status / Income SourceEmployment Full-Time Part-Time Correctional Facility EIA Retired Short-Term Disability Long-Term Disability Employment Insurance-EI Volunteer/Service Work Student Work at Home Employed Full-Time: EmployerEmployed Part-Time: EmployerCorrectional FacilityWork at HomeStudent at (program)Volunteer/Service Work at:MedicationAre you currently taking prescription medication for physical or mental health reasons?*YesNoMedication Name 1Medication Purpose 1Medication Name 2Medication Purpose 2Medication Name 3Medication Purpose 3Medication Name 4Medication Purpose 4Medication Name 5Medication Purpose 5Medication Name 6Medication Purpose 6Medication Name 7Medication Purpose 7Medication Name 8Medication Purpose 8Addiction/Treatment HistoryWhat are the current circumstances that have motivated you to apply to Tamarack Recovery Centre?*What is your drug of choice?*Date last used?* Date Format: MM slash DD slash YYYY Please list other drugs used:How frequently do you typically use substances?*What withdrawal symptoms have you experienced when you have tried to stop using?*Have you ever overdosed (accidentally or otherwise)?*YesNoOn which substance did you overdose?When did you overdoes?What other addictive behaviours do you currently struggle or have you struggled with? Gambling/Gaming Spending Internet Food Sex Relationships Other other addictive behaviour:Previous Treatment Programs AttendedPrevious Treatment Program Name 1Previous Treatment Program Date 1 Date Format: MM slash DD slash YYYY Previous Treatment Program 1 - Complete Program? Yes No Previous Treatment Program 1 - What did you gain?Previous Treatment Program Name 2Previous Treatment Program Date 2 Date Format: MM slash DD slash YYYY Previous Treatment Program 2 - Complete Program? Yes No Previous Treatment Program 2 - What did you gain?Previous Treatment Program Name 3Previous Treatment Program Date 3 Date Format: MM slash DD slash YYYY Previous Treatment Program 3 - Complete Program? Yes No Previous Treatment Program 3 - What did you gain?Are Self-Help Groups (e.g. AA/CA/Refuge for Recovery/SOS/SMART) part of your Recovery Plan? Yes No LegalCriminal/ Civil Charges Pending*YesNoOutstanding Warrants*YesNoRestraining Orders*YesNoCourt Hearing Dates*YesNoBail (probations) Conditions*YesNoPlease provide details of current and past charges as referenced above.Personal GoalsAt this point in time do you feel that there are any barriers or challenges to you being able to access residential treatment at Tamarack (financial, personal, motivational, mental or physical, for example)?*YesNoPlease describe your barriers or challengesWhat goals would you like to achieve by coming to Tamarack?Is there any additional information you would like us to know?Please note: We reserve the right to terminate a client’s stay if the information on the application form is later found to be deliberately incorrect or new information emerges that has been deliberately withheld.