Basic Information

Physical Health

Mental Health

Employment & Education

Legal History

Substance Abuse

GAIN Screener

Please complete all aspects of the Addictions Services Application Package. Incomplete applications will not be processed. Please note that there is no direct entry to the Anchorage Program: all clients will enter residential services through the Stabilization Program. *PLEASE BE AWARE THAT ELECTRONICS INCLUDING CELL PHONES ARE NOT PERMITTED IN OUR PROGRAMS AT ANY TIME*

First Name

Middle Name

Last Name

Date of Birth

Source of Income

Marital Status

Street Address (Including City)

Phone Number

Email

Can we leave messages?

Do you identify as a member of a visible minority?
YES NO

Do you identify as a person of Aboriginal descent?
YES NO

What is your primary language?

If English is not your primary language, are you able to receive services in English?
YES NO

Status in Canada
Canadian Citizen YES NO
Langed Immigrant YES NO
Other

Referral Source?
Ottawa Withdrawal Management Centre Correctional facility/Legal System Community (friend, family member) Other

Emergency Contact Name

Phone Number

Relationship

Family Doctor's Name

Address of Clinic

Date of your last visit

Reason for your visit

How many times have you been hospitalized in the past year?

Please describe the reasons for any hospitalizations in the past year

Do you have any allergies to foods or medications?
YES NO

If yes, to what?

Do you have any dietary restrictions?
YES NO

If yes, please describe:

Do you have a history of seizures?
YES NO

If yes, please describe:

Are you currently taking any medications?
YES NO

If you are taking any (prescription or over-the-counter) medications, please state them below

Medication	Dose	Reason	How long have you been taking it?	Are you taking it as prescribed?

Have you previously been prescribed any medications that you are not currently taking?
YES NO

If yes, please state which medications and why you have stopped taking them:

Do you have any serious medical conditions or issues wih mobility?
YES NO

TOLL FREE CONTACT PHONE LINE IS 1-866-446-3030 EXT 306

PLEASE NOTE
Clients can be accepted into Addictions Services while on various types of medications. During the intake process, a medication review will take place by our partners at Respect Rx. All prescriptions will be transferred to Respect Rx for proper packaging and distribution.
*In medically EXCEPTIONAL circumstances, the Addiction Services clinical team may consider after Intake and medication review, that the individual may not be suited for the programs within Addictions Services.
Please note that any changes to medication(s) MUST be discussed with your primary counsellor and reviewed by our Partners at Respect Rx.

Are you in agreement to the above specifications?
YES No

Do you currently use any opiate replacement therapies (ie. Methadone, suboxone)?*
YES NO

We welcome clients who are on opiate replacement therapies. Clients who are new to program may be referred to a doctor if they wish.
*Please be aware that clients are NOT permitted to store methadone anywhere on site. Clients must have their methadone dispensed daily from a clinic or pharmacy. Suboxone is accepted on site and is taken in front of a staff member. Additionally, clients are not permitted to start opiate replacement therapies once in Anchorage.
Are you in agreement to the policies surrounding the use of opiate replacement therapies? YES or NO
YES No
*Please note if you answer no to abiding by our opiate replacement therapy policies, we will not be able to accept you into the program.

Please Note:
Please know that a history of mental health issues does not exclude you from accessing services. In order to best meet the needs of clients in our programs, we request information regarding your mental health history.

Have you ever been diagnosed with a mental health disorder (including but not limited to anxiety, depression, ADHD, schizophrenia, etc...
YES NO

If yes, please describe:

Have you ever received treatment related to a mental health concern before?
YES NO

If yes, please sate where and when

Do you believe that you require mental health support?
YES NO

If yes, please describe:

Have you ever had thoughts of suicide?
YES NO

Have you ever attempted suicide?
YES NO

If yes, Please state the number of times and date of the most recent attempt:

Do you currenlty have thoughts of suicide?
YES NO

Please Note:
While in Stabilization & Anchorage, clients are not permitted to work for the purpose of generating income.

Will you be able to commit to not working while in recovery within Addiction Services?
YES NO

What was your previous area of work?

Education Note:
It is our mission to do our best to serve everyone, regardless of educational abilities or needs. Groups as part of Addictions Services at The Salvation Army Ottawa Booth Centre are taught using many different styles of instruction and require the ability to read and complete written work. We would like to know about any additional support you may need in order to be able to fully participate in our programs.

Do you require any assistance in being able to read or complete written work?
YES NO

If yes, what do you require?

What is the highest level of education you have completed?

Have you ever been diagnosed with a learning or developmental disability?
YES NO

If yes, please describe:

Please Note:
A history of violent offences does not necessarily exclude you from participating in programming. However, we do want to gather some information in order to best serve you. Staff may also request information pertaining to criminal charges if necessary.

Are you currently involoved in the legal system?
YES NO

Do you have charges pending?
YES NO

If yes, please state your pending charges:

Are you (or will you be) on bail, probation, or parole?
YES NO

Do you have a Probation/Parole Officer or a Surety?
YES NO

If yes, please provide their name and contact information:

Do you have a lawyer?
YES NO

If yes, please provide their name and contact information:

Is it mandatory for you to be in a treatment program?
YES NO

Have you ever been convicted of a violent offence?
YES NO

If yes, please state the nature of the offence(s):

Today's Date

Presenting Substance Abuse Disorder Issues

Substance of Choice	How much do you normally use at one time?	How often do you use this substance?	How do you use this substance? (smoke, inject, etc)	How long has this substance use been a problem for you?	Date of last use

Please note that the Addictions Services programs requires a minimum of 24 hours of sobriety prior to intake. In some circumstances, staff may request clients directly from a withdrawal management service. For clients who use marijuana, there is an expectation that urine screens will be negative for THC six (6) weeks following their intake date. Clients may be discharged from program if urine screens after 6 weeks are not negative for THC.

Do you identify as having a co-occurring addiction (gambling, sex, shopping, etc.)?
YES NO

If yes, explain:

COVID-19 Vaccination Requirements
Double vaccinated only accepted.
Are you double vaccinated?
YES NO

Have you ever been to a treatment program for substance use in the past?
YES NO

If yes, please complete the following table:

Name of Agency	Dates	Length of Program	Did you complete the program?	If you did not complete the program, what was the reason?

The Stabilization Program is available to support you for up to 90 days while you work towards your goals in recovery. While in Stabilization, many clients pursue long-term treatment.
Please describe where you plan on going after Stabilization (i.e. Anchorage, other treatment programs, safe housing, etc.):

Please be aware that the Stabilization program is located in an emergency shelter setting. The program is located on the 4th floor of the building and the bedrooms are shared by two to four residents each.

Are you comfortable living in a communal living setting?
YES NO

Have you ever had any problems with communal living?
YES NO

If yes, please describe:

In signing below, I acknowledge that all of the information in this application is true to the best of my knowledge. I also agree to all of the expectations defined in this application.

I acknowledge that all the information in this application that I have provided is true to the best of my knowledge. I also agree and consent to all of the expectations defined in this application.

The following questions are about common psychological, behavioral, and personal problems. These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can’t go on.

When was the last time that you had significant problems with...

	Answer
feeling very trapped, lonely, sad, blue, depressed, or hopeless about the future?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
becoming very distressed and upset when something reminded you of the past?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
thinking about ending your life or committing suicide?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
seeing or hearing things that no one else could see or hear or feeling that someone else could read or control your thoughts?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse

When was the last time that you did the following things two or more times?

	Answer
Lied or conned to get things you wanted or to avoid having to do something	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
Had a hard time paying attention at school, work, or home	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
Had a hard time listening to instructions at school, work, or home	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
Had a hard time waiting for your turn	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
Were a bully or threatened other people	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
Started physical fights with other people	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
Tried to win back your gambling losses by going back another day	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse

When was the last time that...

	Answer
you used alcohol or other drugs weekly or more often?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
you spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or feeling the effects of alcohol or other drugs?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
you kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
your use of alcohol or other drugs caused you to give or reduce or have problems at important activities at work, school, home, or social events?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
you had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still, or sleeping, or you used any alcohol or other drugs to stop being sick or avoid withdrawal problems?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse

When was the last time that you...

	Answer
had a disagreement in which you pushed, grabbed, or shoved someone?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
took something from a store without paying for it?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
sold, distributed or helped to make illegal drugs?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
drove a vehicle while under the influence of alcohol or illegal drugs?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
purposely damaged or destroyed property that did not belong to you?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse

When was the last time you had significant problems with… (not related to alcohol/drug use)

	Answer
missing meals or throwing up much of what you did eat to control your weight?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
eating binges or times when you ate a very large amount of food within a short period of time and then felt guilty?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
being disturbed by memories or dreams of distressing things from the past that you did, saw, or had happen to you?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
thinking or feeling that people are watching you, following you, or out to get you?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
videogame playing or internet use that caused you to give up, reduce, or have problems with important activities or people of work, school, home or social events?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse
gambling that caused you to give up, reduce, or have problems with important activities or people at work, school, home, or social events?	Past month 2 to 3 months ago 4 to 12 months ago 1+ years ago Never Don't know Refuse

Do you have other significant psychological, behavioural, or personal problems that you want treatment for or help with?
YES NO

If yes, please describe

What is your gender? (If other, please describe)

How old are you today?
years

How many minutes did it take you do complete this survey?

Type the numbers

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