Apply for Treatment – Thorpe Recovery Centre

Applicant Information

Program/Services(Required)

Detox Only

Residential Program

Detox & Program

Funding Options(Required)

AB Funded

SK Funded

Private Pay

GENERAL INFORMATION

LEGAL Name(Required)

First Middle Last

Preferred Name

Alias

Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone(Required)

Alternate Phone(Required)

Email(Required)

Gender(Required)

Ethnicity(Required)

Indigenous(Required)

Status #

Date of Birth(Required)

Current Age(Required)

Please enter a number from 1 to 99.

Provincial Health Number(Required)

Province(Required)

Medical Benefits # (if applicable)

Carrier #

Group or Plan #

Certificate / Member #

How did you hear about the Thorpe Recovery Centre?(Required)

Do you have any relationships- personal or otherwise, with any TRC staff?(Required)

If Yes, please list staff names

EMERGENCY CONTACT INFORMATION

EMERGENCY CONTACT

Name(Required)

Relationship(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone(Required)

Phone

Email(Required)

2ND EMERGENCY CONTACT

Name

Relationship

Address

Street Address Address Line 2 City Province Postal Code

Phone

Alternate Phone

REFERRAL SOURCE INFORMATION

Referral Source(Required)

Referral Source Name(Required)

Agency

Phone(Required)

Fax

Email(Required)

ADDICTION HISTORY

Please list substances used (past and present) including drugs, alcohol, solvents, prescriptions, over the counter medications, and behaviours. Use an * to indicate your primary addiction and ** for your secondary

List(Required)

SUBSTANCE

AMOUNT USED

DAILY/WEEKLY/MONTHLY (if alcohol, specify daily or binge drinking)

DATE OF LAST USE

AGE OF FIRST USE

CONSIDERED PROBLEMATIC (yes/no)

Have you ever used carfentanyl or fentanyl?

If yes, when?

What are your current withdrawal symptoms, if any?(Required)

What was your past withdrawal experience like?(Required)

Do you have a history of overdose?(Required)

Have you had a previous seizure?(Required)

If yes, where? (home, hospital, etc)

Delirium Tremens is the most severe form of alcohol withdrawal and is a medical emergency. It is characterized by profound confusion. It may also include agitation, disorientation, hallucinations, fever, high blood pressure, sweating, high pulse and even cardiovascular collapse. It is usually treated in Intensive Care Units.

I HAVE READ THE ABOVE DESCRIPTION PRIOR TO ANSWER THE FOLLOWING QUESTIONS(Required)

type your initials

Have you ever had delirium tremens?(Required)

When?

Where was it treated?

How long did it last?

Have you ever been admitted to a hospital due to alcohol or drug withdrawal?(Required)

When?

Where was it treated?

How long did it last?

Have you ever been admitted to an Intensive Care Unit due to alcohol or drug withdrawal?(Required)

When?

Where was it treated?

For how long?

Drug-induced psychosis happens when you experience episodes of psychosis, such as delusions or hallucinations, as a direct result of substance abuse.

I HAVE READ THE ABOVE DESCRIPTION PRIOR TO ANSWER THE FOLLOWING QUESTIONS(Required)

type your initials

Have you experienced drug-induced psychosis?(Required)

When?

Where was it treated?

How long did it last?

A seizure is a sudden, uncontrolled burst of electrical activity in the brain. It can cause changes in behaviour, movements, feelings, and levels of consciousness. It often results in convulsions.

I HAVE READ THE ABOVE DESCRIPTION PRIOR TO ANSWER THE FOLLOWING QUESTIONS(Required)

type your initials

Have you ever had a seizure?(Required)

When?

Where dd it happen?

How long did it last?

Benzodiazepines are commonly used medications that produce sedation, relieve anxiety, and reduce seizures. Commonly used benzodiazepines include Ativan, Valium, Restoril, Clonazepam, Xanax.

I HAVE READ THE ABOVE DESCRIPTION PRIOR TO ANSWER THE FOLLOWING QUESTIONS(Required)

type your initials

Have you ever used benzodiazepines?(Required)

When did you start taking them?

How often do you use them?

Are you currently pregnant?(Required)

Have you ever been affected by alcohol/drug use, gambling/process addictions of family members?(Required)

MEDICAL HISTORY

Primary Physician(Required)

Office Address(Required)

Street Address Address Line 2 City Province Postal Code

Office Phone(Required)

Office Fax

Have you had any medical conditions/illnesses within the past two years?(Required)

If yes, identify:

Do any of the following conditions apply:

History of kidney or liver failure, pulmonary failure (ex: COPD) and complex conditions(Required)

If yes, please explain

Known Allergies (environmental, food, medication, ect.)(Required)

If yes, please explain

Do you have any special dietary requirements (cultural or Intolerances)?(Required)

If yes, please explain

Do you have any issues that require accommodation? (hearing loss, mobility etc.)(Required)

If yes, please explain

Do you have trouble with sleeping?(Required)

Apnea

Night Terrors

Staying Asleep

Falling Asleep

Snoring

Sleepwalking

None

Select Up To 3 If Necessary

Are you affected by any of the following?(Required)

Scabies

Lice

Bed bugs

None

Select Up To 3 If Necessary

PSYCHOLOGICAL AND MENTAL HEALTH INFORMATION

Are you currently seeing a mental health professional(Required)

Please chose

Psychiatrist

Psychologist

Therapist

Other

Name

City

Phone

Do you have a current formal mental health diagnosis?

Please specify

Current Medications

Medication

Dosage

Reason

Have you had any suicidal thoughts or attempts in the past year?(Required)

When?

What happened?

Do you currently have any suicidal thoughts or are planning an attempt?(Required)

What is your plan?

With who?

Do you have a history of self-harm behaviours?(Required)

Please specify

Have you received or inquired for help with this?

Please specify

INCOME AND EDUCATION

Income Source(Required)

Length of Current Status

Occupation

What is your highest level of completed Education(Required)

Do you have a learning disability?

None

ADHD

Comprehension

Processing Deficits

Reading

Non-verbal

Writing

Other

FAMILY AND SOCIAL HISTORY

What is your partnership status?(Required)

Do you have any concerns regarding your relationships or non-relationships? Please explain:

Do you have children?(Required)

Please list

Name

Age

Sex

Do they live with you?

Do you have any concerns regarding your relationship with your children? Please describe your concerns:

HOUSING

Do you have a permanent residence?

With whom are you living with

For how long?

Do you currently live with anyone who has a substance use disorder?(Required)

GAMBLING & GAMING HISTORY

Do you have a history of gambling?(Required)

describe

Which types of gambling (past and present) have you participated in?

How long have you been playing the above game(s) and how often do you gamble?

How long have you recognized gambling as problem?

What are you main concerns about your gambling at this time?

DISORDERED EATING

Have you ever been diagnosed with an eating disorder?(Required)

Do you often think about food, weight, and body image?(Required)

Do you use food to cope with emotions and stressful situations?(Required)

SEX LOVE & RELATIONSHIP

Have you ever engaged in sexual activities to cope with emotions and stressful situations?(Required)

Do you ever feel out of control with your sexual behaviors or relationship patterns?(Required)

Have you had any negative consequences because of compulsive sexual/relationship behaviors?(Required)

TOBACCO USE

Do you smoke cigarettes?(Required)

Do you currently use an e-cigarette/vape?(Required)

Do you currently chew tobacco?(Required)

TREATMENT AND DETOX

Is this your first time accessing any form of treatment?(Required)

Have you previously accessed or received treatment at Thorpe Recovery Centre?

Date(s)

Did you complete the program?

Have you previously attended detox/or residential programming at another centre?

Details

Where?

When?

Did you complete the program?

Reason?

TRAUMA/LOSS

Have you experienced any of the following types of abuse/trauma?(Required)

None

Sexual Abuse

Physical Abuse

Emotional Abuse

Domestic Violence

Other

Select As Many As Needed

Have you experienced any of the following types of significant life losses?(Required)

None

Death

Health Problm/Change

Divorce/Separation

Loss of Job/School

Other

Are you experiencing any of the following concerns?(Required)

LEGAL HISTORY

If you are on conditions you must provide a copy with application.

Drop files here or

Accepted file types: jpg, pdf, doc, Max. file size: 64 MB, Max. files: 10.

Do you have any of the following issues?

None

Parole

Probation

Bail

Conditional Sentence

Incarceration (including remand)

House Arrest

Child & Family Orders

Please list any no contact orders if any

Do you have any past charges?(Required)

Please explain

Do you have any outstanding legal charges?(Required)

Please explain

Upcoming court date(s):

Do you have any other legal issues?(Required)

Please explain

Probation Officer or Bail Supervisor Name:

Phone

Legal Counsel:

Firm:

Phone

GOALS

What are your goals for treatment at the Thorpe Recovery Centre?(Required)

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