Contact Name at referring agency(ies) Phone # Email: Who will manage your family Name: Phone: and money while in treatment? Address: Email: Lot #: □Disability □Ontario Income Source: Disability □Employment □Ontario Works □Employment □Other Insurance EI □Family □Other Support Insurance excluding EI □None □Retirement Income □No □Some Education: formal Schooling College/CEGEP/Nursing (Highest level achieved) □Some □Completed Primary school College/CEGP/Nursing □Competed □Some Primary School University (not completed) □Some □Completed Secondary School University Degree/Masters □Completed □PHD High School □(Self) □Disability Employment Status: Employed Full-time □Employed □Not Part-time in Labour Force (eg homemaker) □Unemployed □Retired (looking for □Artist work) (self-employed) □Student/ Re-training Previous Substance Treatment □Yes □No Are you Currently getting Counselling from your community? If yes, give contact information: How long? □Yes □No Have you had previous substance treatment? (If yes, complete chart below) Treatment Facility / Location Type of treatment Date Amended (mm/yy) Program Length □Yes □No Have had previous treatment at Mamisarvik? If yes, when? Family Background Married Widow/Widower Please identify your current relationship status: Partnered/Common Law Divorced/Separated Single (never married) Birth Place: Please identify your immediate family members below: Do you have Are they Do they Family member name Relationship Age contact with supportive of abuse drugs them? treatment? or alcohol?
Contact Name at referring agency(ies) Phone # Email: Who will manage your family and money while in treatment? Name: Address: Lot #: Phone: Email: Income Source: □Disability □Employment □Employment Insurance EI □Family Support □None □Ontario Disability □Ontario Works □Other □Other Insurance excluding EI □Retirement Income Education: (Highest level achieved) □No formal Schooling □Some Primary school □Competed Primary School □Some Secondary School □Completed High School □Some College/CEGEP/Nursing □Completed College/CEGP/Nursing □Some University (not completed) □Completed University Degree/Masters □PHD Employment Status: □(Self) Employed Full-time □Employed Part-time □Unemployed (looking for work) □Student/ Re-training □Disability □Not in Labour Force (eg homemaker) □Retired □Artist (self-employed) Previous Substance Treatment Are you Currently getting Counselling from your community? □Yes □No If yes, give contact information: How long? Have you had previous substance treatment? □Yes □No (If yes, complete chart below) Treatment Facility / Location Type of treatment Date Amended (mm/yy) Program Length Have had previous treatment at Mamisarvik? □Yes □No If yes, when? Family Background Please identify your current relationship status: Married Widow/Widower Partnered/Common Law Divorced/Separated Single (never married) Birth Place: Please identify your immediate family members below: Family member name Relationship Age Do you have contact with them? Are they supportive of treatment? Do they abuse drugs or alcohol?