Intake Online Form Intake Form Date 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?* Yes No Cell PhoneCell Phone Messages OK?* Yes No Other PhoneOther Phone Messages OK?* Yes No Date of Birth* 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-describe Preferred 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: Employer Employed Part-Time: Employer Correctional Facility Work at Home Student at (program) Volunteer/Service Work at: MedicationAre you currently taking prescription medication for physical or mental health reasons?* Yes No Medication Name 1 Medication Purpose 1 Medication Name 2 Medication Purpose 2 Medication Name 3 Medication Purpose 3 Medication Name 4 Medication Purpose 4 Medication Name 5 Medication Purpose 5 Medication Name 6 Medication Purpose 6 Medication Name 7 Medication Purpose 7 Medication Name 8 Medication Purpose 8 Addiction/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?* 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)?* Yes No On 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 1 Previous Treatment Program Date 1 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 2 Previous Treatment Program Date 2 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 3 Previous Treatment Program Date 3 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* Yes No Outstanding Warrants* Yes No Restraining Orders* Yes No Court Hearing Dates* Yes No Bail (probations) Conditions* Yes No Please 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)?* Yes No Please 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.