East Kootenay Addiction Services Society

First Name

Last Name

Personal Health Care Number

Birth Date

Gender

Street Address, Box Number, City and Postal Code

Primary Phone Number

OK to leave a message at this number?

Yes

No

Alternate Phone Number

OK to leave a message at this number?

Yes

No

Email Address

OK to contact you at this email?

Yes

No

Family Physician/Nurse Practitioner

Are you concerned about?

Your own substance use

Someone else's substance use

If you are here for your own use, what substance or substances are you most concerned about presently?

If you are here because of someone else's substance use, what is your relationship with that person:

Who recommended that you contact us?

Self

Family

Probation

Doctor

MCFD

School

Employer

Other (specify)

What are your specific expectations/goals for being seen at East Kootenay Addiction Services?

Are you interested in the Opioid Agonist Therapy (OAT) Program? (Methadone/Suboxone/Sublocade)

Yes

No

Are you currently receiving counselling or support from any other service?

Yes

No

What form(s) of counselling would you prefer?

In person

Phone

Video/Zoom

Client Intake Form