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*

Your Full Name

Date of Birth

Phone Number

Can we leave messages?

Email

Street Address (Including City)

Source of Income

Marital Status

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?

Please identify other languages you are able to communicate in:

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

How did you hear about the Stabilization Program?
Ottawa Withdrawal Management Centre Correctional facility/Legal System Community (friend, family member) Other

Emergency Contact

Phone Number

Relationship

Family Doctor

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

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

PLEASE NOTE
Clients can be accepted into Addictions Services while on various types of medications. During the intake process, a medication review will be conducted by our partners at Respect Rx. After this review, 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 counselor and reviewed by our partners at Respect Rx.

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

Are you in agreement with the policies surrounding the use of opiate replacement therapies?
YES I agree with all the terms and conditions

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 Stabilization (and Anchorage)?
YES NO

What was your previous area of work?

The last date you worked?

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:
*That no matter what level of literacy or ability, this will not impact your acceptance to service. We will accept all levels of client literacy and learning ability.

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

Substance of Choice

How much do you normally use at one time?

How often do you use the substance?
Everyday Once every few days Once a week Once a month

How do you use this substance? (smoke, inject, etc)

How long has this substance use been a problem from you?

Date of Last Use

The Stabilization program requires a minimum of 24 hours of sobriety prior to intake. In some circumstances, staff may contact and request clients directly from the Ottawa Withdrawal Management Centre. 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:

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

If yes, Name of agency

Length of Program From To

Did you complete the program?
YES NO

If you did not complete the program, what was the reason?

Please describe where you plan on going after Stabilization (i.e. Anchorage, other treatment programs, safe housing, etc.):

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:

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 or safe housing. The Salvation Army Ottawa Booth Centre is a social services ministry unit of The Salvation Army church. We provide effective, client-centered programs and services, which respond to physical, emotional, and spiritual needs and are given with respect and dignity for all. Since there is proven value in spiritual care for well-being and connection, Addictions Services include for clients in the program: • Daily chapel services to motivate and inspire • Spirituality class to explore personal beliefs and values and to discover how faiths and spirituality can be transformational and empowering. Various faiths and customs are explored. • Opportunity for individual pastoral counseling sessions for added support and spiritual resources

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, 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 you feel like you can't go on.

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

	Past month	2 to 3 months ago	4 to 12 months ago	1+ years ago	Never
feeling very trapped, lonely, sad, blue, depressed, or hopeless about the future?
sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?
feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen?
becoming very distressed and upset when something reminded you of the past?
thinking about ending your life or committing suicide?
seeing or hearing things that no one else could see or hear or feeling that someone else could read or control your thoughts?

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

	Past month	2 to 3 months ago	4 to 12 months ago	1+ years ago	Never
Lied or conned to get things you wanted or to avoid having to do something
Had a hard time paying attention at school, work, or home
Had a hard time listening to instructions at school, work, or home
Had a hard time waiting for your turn
Were a bully or threatened other people
Started physical fights with other people
Tried to win back your gambling losses by going back the next day

When was the last time that...

	Past month	2 to 3 months ago	4 to 12 months ago	1+ years ago	Never
you used alcohol or other drugs weekly or more often?
you spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or recovering from the effects of alcohol or other drugs? (e.g. feeling sick)
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?
your use of alcohol or other drugs caused you to give or reduce your involvement in activities at work, school, home, or social events?
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?

When was the last time that you...

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

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

	Past month	2 to 3 months ago	4 to 12 months ago	1+ years ago	Never
missing meals or throwing up much of what you did eat to control your weight?
eating binges or times when you ate a very large amount of food within a short period of time and then felt guilty?
being disturbed by memories or dreams of distressing things from the past that you did, saw, or had happen to you?
thinking or feeling that people are watching you, following you, or out to get you?
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?
gambling that caused you to give up, reduce , or have problems with important activities or people of work, school, home, or social events?

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

If yes, please describe

Please select YES or NO for each question.

1. Have you ever been consistently depressed or down, most of the day, nearly every day, for the past 2 weeks?
YES NO

2. In the past 2 weeks, have you been less interested in most things or less able to enjoy the things you used to enjoy most of the time?
YES NO

3. Have you felt sad, low or depressed most of the time for the past two years?
YES NO

4. In the past month, did you think you would be better off dead or wish you were dead?
YES NO

5. Have you ever had a period of time when you were feeling up, hyper, or so full of energy or full of yourself that you got into trouble or that other people thought you were not your usual self? (Do not consider the times when you were intoxicated on drugs or alcohol.)
YES NO

6. Have you ever been so irritable, grouchy or annoyed for several days, that you had arguments, verbal or physical fights, or shouted at people outside your family? Have you or others noticed that you have been more irritable or overreacted compared to other people, even when you thought you were right to act in this way.
YES NO

7. Note this question is in in two parts. a. Have you had one or more occasions when you felt intensely anxious, frightened, uncomfortable or uneasy even when most people would not feel that way?
YES NO

7b. If yes, did these intense feelings get to be at their worst within 10 minutes? YES/NO Interviewer: If the answer to BOTH a and b is NO, code the question NO
YES NO

8. Do you feel anxious or uneasy in places or situations where you might have panic-like symptoms we just spoke about? Or do you feel anxious or uneasy in situations where help might not be available or escaped might be difficult?
YES NO

9. Have you worried excessively or been anxious about several things over the past 6 months?
YES NO

10. Are these worries present most days?
YES NO

11. In the past month, were you afraid or embarrassed when others were watching you? Or when you were the focus of attention? Were you afraid of being humiliated?
YES NO

12. In the past month, have you been bothered by thoughts, impulses, or images that you couldn’t get rid of that were unwanted, distasteful, inappropriate, intrusive or distressing?
YES NO

13. In the past month, did you do something repeatedly without being able to resist doing it?
YES NO

14. Have you ever experienced or witnessed or had to deal with an extremely traumatic event that included actual or threatened death or serious injury to you or someone else?
YES NO

15. Have you re-experienced the awful event in a distressing way in the past month?
YES NO

16. Have you ever believed that people were spying on you, or that someone was plotting against you or trying to hurt you?
YES NO

17. Have you ever believed that someone was reading your mind or could hear your thoughts, or that you could actually read someone’s mind or hear what another person was thinking?
YES NO

18. Have you ever believed that someone or some force outside of yourself put thoughts in your mind that were not your own, or made you act in a way that was not your usual self? Or, have you ever felt that you were possessed?
YES NO

19. Have you ever believed that you were being sent special messages through the TV, radio, or newspaper? Did you believe that someone you did not personally know was particularly interested in you?
YES NO

20. Have your relatives or friends ever considered any of your beliefs strange or unusual?
YES NO

21. Have you heard things other people couldn’t hear, such as voices?
YES NO

22. Have you ever had visions when you were awake or have you ever seen things other people couldn’t see?
YES NO

Type the numbers

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