Addiction Services | Ottawa Booth Centre

Addiction Services Application

Basic Information

Physical Health

Mental Health

Employment & Education

Legal History

Substance Abuse

GAIN Screener

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:

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?
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?

	Answer
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 another day

When was the last time that...

	Answer
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 feeling the effects of alcohol or other drugs?
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 or have problems at important 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...

	Answer
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)

	Answer
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 at 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

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
Captcha image. You must type the numbers shown in the image.

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

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