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Pre-Assessment Form
Date
*
Gender
*
-
Male
Female
Date of Birth
*
Identification
Indicate all valid government issued ID you have
*
Drivers Licence
Provincial Health Card
Social Insurance Card
Other
None
Social Security Number
Drivers License Number
Is your drivers license valid
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Yes
No
Health Card Number
Is your health card valid
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Yes
No
Other Government ID Number
Other Government ID Type
Children
Do you have children?
*
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Yes
No
if you have children, how many?
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1 - 2
3 - 4
5 - 6
7 - 8+
List each child's name, gender and age
Do you have custody of the children?
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Yes
No
if you do not, who has custody?
Have you put a child up for adoption?
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Yes
No
Any other children not listed?
Relationships
Are you in a relationship?
-
Yes
No
Describe the relationship: ex. married, common law, how long you have been together, etc
If married, spouse name
If married, spouse phone
If not married, are you willing to set aside the relationship to focus on your recovery?
If separated, is there a chance of reconciliation?
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Yes
No
Please Explain
Treatment
What are you looking to get help/treatment for? (check all that apply)
Alcohol
Benzodiazepines
Cannabis
Cocaine
Crack
Eating Disorders
Hallucinogens
Heroin
Inhalants
Opioids
Self-Harm
Sexual/Porn
Other
If looking to get help/treatment for other, please specify
Describe any previous treatments/help recieved
Drugs / Medications
Drug of Choice
Date of Last Use
Do you use nicotine?
-
Yes
No
Are you willing to quit nicotine?
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Yes
No
Are you on any psychiatric medications?
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Yes
No
If yes, please describe the psychiatric meds, how long and dosage
Are you on any medication for medical reasons?
-
Yes
No
If yes, please describe the meds, how long and dosage
List any other medications not previously described
Physical
Describe any physical problems. Neck, back, knee, joint, dental, digestive, scoliosis, pain of any kind?
List All Allergies
Bee Stings
Food
Gluten Intolerance
Glucose Intolerance
Medications
Environmental
Other
If other allergies, please specify
Please describe allergies
Legal
Do you currently have any legal troubles?
-
Yes
No
If yes, please describe: Charges, Court dates, Warrants, Probation, etc.
Probation Officer Information
Do you have a probation officer?
-
Yes
No
Name of Probation Officer
Probation Officer Phone
Probation Officer Email
Emergency Contact Information
Emergency Contact Name
Emergency Contact Phone #(s)
Emergency Contact Email Address
Emergency Contact Relationship
Date
Gender
Date of Birth
Identification
Indicate all valid government issued ID you have
Social Security Number
Drivers License Number
Is your drivers license valid
Health Card Number
Is your health card valid
Other Government ID Number
Other Government ID Type
Children
Do you have children?
if you have children, how many?
List each child's name, gender and age
Do you have custody of the children?
if you do not, who has custody?
Have you put a child up for adoption?
Any other children not listed?
Relationships
Are you in a relationship?
Describe the relationship: ex. married, common law, how long you have been together, etc
If married, spouse name
If married, spouse phone
If not married, are you willing to set aside the relationship to focus on your recovery?
If separated, is there a chance of reconciliation?
Please Explain
Treatment
What are you looking to get help/treatment for? (check all that apply)
If looking to get help/treatment for other, please specify
Describe any previous treatments/help recieved
Drugs / Medications
Drug of Choice
Date of Last Use
Do you use nicotine?
Are you willing to quit nicotine?
Are you on any psychiatric medications?
If yes, please describe the psychiatric meds, how long and dosage
Are you on any medication for medical reasons?
If yes, please describe the meds, how long and dosage
List any other medications not previously described
Physical
Describe any physical problems. Neck, back, knee, joint, dental, digestive, scoliosis, pain of any kind?
List All Allergies
If other allergies, please specify
Please describe allergies
Legal
Do you currently have any legal troubles?
If yes, please describe: Charges, Court dates, Warrants, Probation, etc.
Probation Officer Information
Do you have a probation officer?
Name of Probation Officer
Probation Officer Phone
Probation Officer Email
Emergency Contact Information
Emergency Contact Name
Emergency Contact Phone #(s)
Emergency Contact Email Address
Emergency Contact Relationship
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