Instructions: The following form is required to begin the application process to Mamisarvik. The form should be printed and completed by hand, then faxed or mailed to Mamisarvik (info below). For Mamisarvik to complete its assessment intake, we will schedule then an Assessment intake via skype or in person after we have reviewed this application form. Mailing Address: Mamisarvik Healing Centre 1863 Russell Road, Ottawa K1G 0N1 Fax Number: 613-563-3540 Intake Assessment Worker: 613- 563-3546 ext TBA Website: Detailed information on our programs and the assessment process can be found at www.tungasuvvingatinuit.ca Office Use Only Referred On: □Health □Provincial □Federal □Fee-for-Service Status: Corrections Corrections Personal Information First Name: Last Name: Full name at birth (if different from above): If you use an alternate name, please include it: □ □ □Transgender Date of Birth: Gender: Male Female □Yes □No Do you have a valid NTI# NIHB#: Please bring a copy as well □Yes □No Government Photo ID: You will need to bring it with you Home Address: Lot #: City/Settlement: Prov/Territory: □ □No Postal Code: No Fixed Address? Yes Current Location (if different from above) □Yes □No Phone Number: Okay to leave a message? Name of Emergency Contact: Relationship: □Yes □No Emergency Contact Phone # Okay to leave a message? □English □Inuktitut □Other Language you prefer to receive services in? specify □Intergenerational □ □Relocation □Dog □ Trauma History: Residential School Team Slaughter Other Referral Information Please check the line that explains who referred you to Mamisarvik □ □Day/Evening □Correctional Self Addictions Facility □Family/Friend □Psychiatric □Non-Addictions Services Residential □Initial □Psychiatrist/Psychologist □Self-Help Assessment Treatment Plan Group □Withdrawal □Medical □EAP/Employer Management Centre Services □Community □Community □Police Withdrawal Health Centre Management □Residential □Physician/Private □Other Addictions Practice Legal □Supportive □Public □DART/Connex Housing Health Unit Nurse website □Outpatient □Community □Other Addictions Please specify the referring agency(ies)
Instructions: The following form is required to begin the application process to Mamisarvik. The form should be printed and completed by hand, then faxed or mailed to Mamisarvik (info below). For Mamisarvik to complete its assessment intake, we will schedule then an Assessment intake via skype or in person after we have reviewed this application form. Mailing Address: Mamisarvik Healing Centre 1863 Russell Road, Ottawa K1G 0N1 Fax Number: 613-563-3540 Intake Assessment Worker: 613- 563-3546 ext TBA Website: Detailed information on our programs and the assessment process can be found at www.tungasuvvingatinuit.ca Office Use Only Referred On: Status: □Health □Provincial Corrections □Federal Corrections □Fee-for-Service Personal Information First Name: Last Name: Full name at birth (if different from above): If you use an alternate name, please include it: Date of Birth: Gender: □ Male □ Female □Transgender Do you have a valid NTI# □Yes □No NIHB#: Please bring a copy as well Government Photo ID: □Yes □No You will need to bring it with you Home Address: Lot #: City/Settlement: Prov/Territory: Postal Code: No Fixed Address? □ Yes □No Current Location (if different from above) Phone Number: Okay to leave a message? □Yes □No Name of Emergency Contact: Relationship: Emergency Contact Phone # Okay to leave a message? □Yes □No Language you prefer to receive services in? □English □Inuktitut □Other specify Trauma History: □Intergenerational □ Residential School □Relocation □Dog Team Slaughter □ Other Referral Information Please check the line that explains who referred you to Mamisarvik □ Self □Day/Evening Addictions □Correctional Facility □Family/Friend □Psychiatric Services □Non-Addictions Residential □Initial Assessment Treatment Plan □Psychiatrist/Psychologist □Self-Help Group □Withdrawal Management Centre □Medical Services □EAP/Employer □Community Withdrawal Management □Community Health Centre □Police □Residential Addictions □Physician/Private Practice □Other Legal □Supportive Housing □Public Health Unit Nurse □DART/Connex website □Outpatient Addictions □Community □Other Please specify the referring agency(ies)