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  Ontario
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Referral:
Application for Enrollment ID
Date: 2024-12-01 15:29
Status: Draft
Attachment(s):
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Hide/ShowClient Information
Date Submitted:
Select Date Clear Date
Youth First Name:
Last name at birth:
Preferred Name:
Gender:
Youth DOB:
Select Date Clear Date
Home Phone:
Cell Phone:
Youth E-mail:
Address:
City:
County:
Province:
Postal Code:
Ethnicity:
Preferred Language:
OHIP Number:
OHIP Expiry Date:
Select Date Clear Date
OHIP Version Code (two letters):
Extended (i.e. private) health insurance?
If yes, Company name:
Plan Number:
Group Number:
Id Number:
What is your Mother Tongue?
In which of Canada's Official Languages are you most comfortable receiving your healthcare services?
English
French
Relationship Status:
Current Living Status:
With parents
On my own
With friends
Homeless
Shelter
Incarcerated
Other
If Other selected, please describe:
Employment Status:
Employed full-time, includes self employed
Employed part-time
Unemployed (looking for work)
Student/retraining
Disabled (not working)
Not in labour force (e.g. Homemaker)
Retired
Unknown
Income Source:
Employment
Employment Insurance
ODSP (Ontario Disability Support Program)
Disability Insurance
Other Insurance (excluding Employment Insurance)
Ontario Works
Retirement Income
Other
None
Family Support
Unknown
Education Status:
Sexual Orientation:
How did you first hear about Dave Smith Youth Treatment Centre?
If not identified above, please name the specific agency and professional who referred you (unless you self-referred):
Reason(s) for the referral
Hide/ShowDecision to Seek Treatment
What are your main reasons for seeking treatment?
What are you hoping to work on to improve while in treatment?
Is attending treatment a condition/requirement being imposed on you?
None
Choice between treatment or jail
Condition of probation/parole
Child welfare authority
Condition of employment
Condition of school
Condition of family
Other
What would you describe as your strengths?
(intellectually, artistically, socially, physically etc.)
What would you describe as your areas for improvement?
(intellectually, artistically, socially, physically etc.)
Hide/Show Primary Parent/Caregiver Information (dummy_group)
Delete
Relationship:
Legal Custody:
Yes
No
Shared
Other
If Other, please describe:
Name:
DOB:
Select Date Clear Date
Address:
Home Phone:
Permission to call?
Permission to leave message?
Mobile Phone:
Permission to call?
Permission to leave message?
Work Phone:
Permission to call?
Permission to leave message?
Home Email:
Work Email:
Preferred Contact Method(s) - First:
Home phone
Cell phone
Work phone
Home e-mail
Work e-mail
Preferred Contact Method(s) - Second:
Home phone
Cell phone
Work phone
Home e-mail
Work e-mail
How will this person be involved in your treatment?
Hide/Show Primary Parent/Caregiver Information (1)
Delete
Relationship:
Legal Custody:
Yes
No
Shared
Other
If Other, please describe:
Name:
DOB:
Select Date Clear Date
Address:
Home Phone:
Permission to call?
Permission to leave message?
Mobile Phone:
Permission to call?
Permission to leave message?
Work Phone:
Permission to call?
Permission to leave message?
Home Email:
Work Email:
Preferred Contact Method(s) - First:
Home phone
Cell phone
Work phone
Home e-mail
Work e-mail
Preferred Contact Method(s) - Second:
Home phone
Cell phone
Work phone
Home e-mail
Work e-mail
How will this person be involved in your treatment?
Add Section Add Primary Parent/Caregiver Information
Hide/ShowFamily Information
What is your mother's current marital status?
Married
Divorced
Separated
Widowed
Single
Life Partners
If separated or divorced, how old were you at the time?
What is your father's current marital status?
Married
Divorced
Separated
Widowed
Single
Life Partners
If separated or divorced, how old were you at the time?
Has the Children's Aid Society (CAS) been involved with your family?
*Note - If you are currently involved with CAS, please provide a copy of your plan of care with your application.
Yes
No
Unknown
If yes, how old were you at the time?
Are you a parent yourself?
Yes
No
Unsure
If yes, please provide details regarding the age(s) of your child(ren), if you have custody of your child(ren) and if so, what arrangements have been made to have your child(ren) cared for while you are in treatment:
Hide/Show Family Information Cont. (dummy_group)
Delete

Please list any siblings (including any step or half siblings):

Name:
Age:
Gender:
Relationship:
Full Sibling
Half Sibling
Step Sibling
Adopted Sibling
Other
Currently live with?
Any Substance Use or Mental Health Problems?
Hide/Show Family Information Cont. (1)
Delete

Please list any siblings (including any step or half siblings):

Name:
Age:
Gender:
Relationship:
Full Sibling
Half Sibling
Step Sibling
Adopted Sibling
Other
Currently live with?
Any Substance Use or Mental Health Problems?
Add Section Add Family Information Cont.
Hide/ShowSubstance Use History
Primary Presenting problem substance:
Alcohol
Amphet. & other stimulants exc. methamphetamines
Barbiturates
Benzodiazepines
Cannabis
Cocaine
Crack
Ecstasy
GIue & other inhalants
Hallucinogens
Heroin/Opium
Methamphetamines i.e crystal meth
Other psychoactive drugs
Over-the-counter codeine preparations
Prescription opioids
Steroids
Tobacco
Unknown
Frequency in the last 30 days - primary presenting problem substance:
Did not use
1-3 times monthly
1-2 times weekly
3-6 times weekly
Daily
Binge
Unknown
Hide/Show Substance Use History (dummy_group)
Delete
Substance used in the last 30 days:
Alcohol
Hallucinogens
Amphet. & other stimulants exc. methamphetamines
Heroin/Opium
Barbiturates
Methamphetamines i.e crystal meth
Benzodiazepines
Other psychoactive drugs
Cannabis
Over-the-counter codeine preparations
Cocaine
Prescription opioids
Crack
Steroids
Ecstasy
Tobacco
GIue & other inhalants
Unknown
Frequency of use:
Did not use
1-3 times monthly
1-2 times weekly
3-6 times weekly
Daily
Binge
Unknown
Hide/Show Substance Use History (1)
Delete
Substance used in the last 30 days:
Alcohol
Hallucinogens
Amphet. & other stimulants exc. methamphetamines
Heroin/Opium
Barbiturates
Methamphetamines i.e crystal meth
Benzodiazepines
Other psychoactive drugs
Cannabis
Over-the-counter codeine preparations
Cocaine
Prescription opioids
Crack
Steroids
Ecstasy
Tobacco
GIue & other inhalants
Unknown
Frequency of use:
Did not use
1-3 times monthly
1-2 times weekly
3-6 times weekly
Daily
Binge
Unknown
Add Section Add Substance Use History
Hide/ShowSubstance Use History
Please indicate each of the substances that you have used in the past 12 months:
Alcohol
Crack
Other psychoactive drugs
Amphet. & other stimulants exc. methamphetamines
Ecstasy
Over-the-counter codeine preparations
Barbiturates
GIue & other inhalants
Prescription opioids
Benzodiazepines
Hallucinogens
Steroids
Cannabis
Heroin/Opium
Tobacco
Cocaine
Methamphetamines i.e crystal meth
Unknown
Have you ever used needles to inject substances?
Never injected
Injected prior to one year ago
Injected in the last 12 months
Unknown
Please describe any other drugs not listed above that you have had experience with (either through personal use or through friends):
How soon after you wake up do you smoke your first cigarette?
Within 5 minutes
6-30 minutes
31-60 minutes
After 60 minutes
Do you find it difficult to not smoke in places where it is forbidden, such as school, work, or restaurants?
Which cigarette would you hate most to give up?
The first one in the morning
Any others
How many cigarettes do you smoke daily?
10 or less
11-20
21-31
31 or more
Do you smoke more frequently during the first hours after waking than the rest of the day?
Do you smoke even when you are so ill that you are in bed most of the day?
Hide/ShowSchool/Education Information
Have you completed secondary/high school?
Are you currently attending school?
Are you currently behind in credits?
How many credits do you need to graduate?
How many student volunteer hours do you need to graduate?
What is the highest grade you have completed?
1
2
3
4
5
6
7
8
9
10
11
12
Some College
Name and location of Current School (if enrolled):
Name and location of Previous School:
Have you ever been assessed for learning disabilities?
ie: reading/writing/math disorder, ADHD, ADD
Yes
No
Unknown
If yes, please describe:
*Note - Please provide a copy of this assessment with your application.
Have you ever had an individualized education plan (IEP)?
*Note - Please provide a copy of your most recent IEP with your application.
Yes
No
Unknown
Have you ever been suspended or expelled from school?
Yes
No
Unknown
If yes, please give dates and reasons:
Hide/ShowMental Health History
Substance Use and Mental Health Assessment and Diagnosis History
Have you been diagnosed with a mental health problem by a qualified mental health professional in the last 12 months?
Yes
No
Unknown
If yes, please describe (including professional's name and diagnosis):
Have you been diagnosed with a mental health problem by a qualified mental health professional in your lifetime?
Yes
No
Unknown
If yes, please describe (including professional's name and diagnosis):
* Note - Please provide a copy of the assessment summaries
Substance Use and Mental Health Treatment History
Are you currently receiving treatment for substance use or mental health problems from a community mental health program or professional?
Yes
No
Unknown
Have you received treatment for substance use or mental health problems from a community mental health program or professional in the last 12 months?
Yes
No
Unknown
Have you received treatment for substance use or mental health problems from a community mental health program or professional in your lifetime?
Yes
No
Unknown
Hide/Show Substance Use and Mental Health Treatment History Cont. (dummy_group)
Delete

Please list all previous, relevant treatment for substance use and mental health problems (including residential, outpatient, day treatment) in this section

*Note - Please provide a copy of treatment/discharge summaries for each of these. 

Agency/Professional Name:
Contact Information:
Dates:
Reason for treatment, type of treatment and outcomes:
(i.e. Were you helped? Did you complete treatment?)
Can we contact this provider for more information?
Hide/Show Substance Use and Mental Health Treatment History Cont. (1)
Delete

Please list all previous, relevant treatment for substance use and mental health problems (including residential, outpatient, day treatment) in this section

*Note - Please provide a copy of treatment/discharge summaries for each of these. 

Agency/Professional Name:
Contact Information:
Dates:
Reason for treatment, type of treatment and outcomes:
(i.e. Were you helped? Did you complete treatment?)
Can we contact this provider for more information?
Add Section Add Substance Use and Mental Health Treatment History Cont.
Hide/ShowSubstance Use and Mental Health Medication History
Are you currently taking Methadone, Suboxone or other opioid substitute?
Yes
No
Unknown
If yes, please provide the subscribing doctor's name and clinic:
Are you currently prescribed medication for a mental health problem?
Yes
No
Unknown
Hide/Show If yes, please provide the following information (dummy_group)
Delete
Medication Name:
Dosage:
Frequency:
(How many doses per day)
What is the medication prescribed for?
How long have you been taking it?
Do you take it as prescribed?
Side effects?
Hide/Show If yes, please provide the following information (1)
Delete
Medication Name:
Dosage:
Frequency:
(How many doses per day)
What is the medication prescribed for?
How long have you been taking it?
Do you take it as prescribed?
Side effects?
Add Section Add If yes, please provide the following information
Hide/Show 
Were you prescribed medication for a mental health problem in the last 12 months?
Yes
No
Unknown
Were you prescribed medication for a mental health problem in your lifetime?
Yes
No
Unknown
Hide/Show If yes and you no longer take the medication (i.e. not in the current list above) please provide the following information: (dummy_group)
Delete
Medication Name:
Dosage:
Frequency:
(How many doses/day?)
What was the medication prescribed for?
How long did you take it?
Why was the medication stopped?
Hide/Show If yes and you no longer take the medication (i.e. not in the current list above) please provide the following information: (1)
Delete
Medication Name:
Dosage:
Frequency:
(How many doses/day?)
What was the medication prescribed for?
How long did you take it?
Why was the medication stopped?
Add Section Add If yes and you no longer take the medication (i.e. not in the current list above) please provide the following information:
Hide/ShowMental Health Hospitalization History
Substance Use and Mental Health Hospitalization History
Have you been hospitalized for a substance use or mental health problem in the last 12 months?
Yes
No
Unknown
Have you been hospitalized for a substance use or mental health problem in your lifetime?
Yes
No
Unknown
Hide/Show If yes to either question, please provide the following information: (dummy_group)
Delete
Hospital Name:
Date:
(month, year)
Length of hospitalization:
Reason for hospitalization:
Hide/Show If yes to either question, please provide the following information: (1)
Delete
Hospital Name:
Date:
(month, year)
Length of hospitalization:
Reason for hospitalization:
Add Section Add If yes to either question, please provide the following information:
Hide/ShowPsychological Health History
Have you had any physical confrontations with others?
If yes, please describe (including how recently and if there were injuries):
Have you ever intentionally hurt yourself?
If yes, please describe including how recently and if you needed medical attention:
Have you ever attempted suicide?
If yes, please describe (specify date, reason, whether you required medical attention and whether you were hospitalized):
Do you have any current eating issues (i.e. binging, purging)?
Have you been diagnosed and treated for an eating disorder?
*Note - If you have received diagnosis and/or treatment for an eating disorder, please submit any relevant documentation with your application package.
How you are doing right now with respect to eating?
Hide/ShowPhysical Health History
What is the name and phone number of your Family Doctor?
Height:
Weight:
Eyes:
Brown
Blue
Blue Green
Green
Hazel
Amber
Grey
Hair:
Brown
Dark Brown
Blonde
Red
Black
Grey
Please describe any tattoos (if applicable):
Please describe any piercings (if applicable):
Please describe any major/noticeable scars (if applicable):
How many times were you hospitalized for a physical health problem in the last 12 months?
Do you have any medical conditions that we should know about?
(i.e. diabetes, seizure disorders, kidney disease, Crohn's disease, epilepsy)
If yes, please describe the condition including any special care required while in treatment:
Do you have any Food allergies?
If yes, please include the following information for each food allergy:
1. What food(s) are you allergic to?
2. What happens if you eat the food you are allergic to?
3. Have you ever been tested for this allergy?
Do you carry an Epipen for this allergy?
Do you have any Medication allergies?
If yes, please include the following information for each medication allergy:
1. What medication(s) are you allergic to?
2. What happens if you are exposed to the medication you are allergic to?
3. Have you ever been tested for this allergy?
4. Do you carry an Epipen for this allergy?
Do you have any Environmental allergies (pollens, bee stings, etc.)?
If yes, please include the following information for each environmental allergy:
1. What are you allergic to in the environment?
2. What happens if you are exposed to the allergen(s)?
3. Have you ever been tested for this allergy?
4. Do you carry an Epipen for this allergy?
5. Do you take any medication for this allergy?
(i.e. antihistamines or allergy shots)
Are you lactose intolerant?
If yes, please specify details about what dairy limitations you use as well as use of dairy substitution products/supplements:
Do you have any dietary restrictions (i.e. vegetarian, kosher, halal)?
If yes, please describe your dietary restrictions in detail:
Do you have any religious, cultural, and creed-based practices that require accommodations?
(e.g.: Religious holy days, days of significance, dress codes, multi-faith prayer/reflection room, and dietary needs)
If yes, please state and describe the accommodation you require below:
Do you have any vision problems?
If yes, do you wear glasses?
If yes, do you wear contacts?
Please describe:
Do you have any hearing problems?
If yes, please describe:
Do you have any mobility problems?
If yes, please describe:
Are you (or could you be) pregnant?
If yes, please describe:
(how far along in the pregnancy, complications, plans regarding the pregnancy)
Hide/ShowLegal/Justice System Information
What is your current legal status?
No problem
Awaiting trial or sentencing
Probation
Parole
Incarcerated
Other
Unknown
Have you been charged with an offence as a Young Offender?
Yes
No
Unknown
Please list your charges and court dates:
Probation Officer:
Parole Officer:
Lawyer:
Thank you for your interest in our program and for submitting your application. Kindly note that one of our Intake Coordinator's will follow up with you by email within 1-2 business days.
 
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