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)
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?
3 □Did not use □1-3 times monthly □1-2 times weekly □3-6 times weekly □Daily □Binge 4 □Did not use □1-3 times monthly □1-2 times weekly □3-6 times weekly □Daily □Binge Please indicate any substances used in the past 12 months (select all that apply): Substance Date Used Method of Use Alcohol □Smoked □Injected □Snorted □Swallowed Amphetamines & other stimulants □Smoked □Injected □Snorted □Swallowed Barbiturates □Smoked □Injected □Snorted □Swallowed Benzodiazepines □Smoked □Injected □Snorted □Swallowed Cannabis □Smoked □Injected □Snorted □Swallowed Cocaine □Smoked □Injected □Snorted □Swallowed Crack □Smoked □Injected □Snorted □Swallowed Ecstasy/MDMA □Smoked □Injected □Snorted □Swallowed Glue/Inhalants □Smoked □Injected
Slot machines Instant win or scratch tickets Gaming machines (other than slots) Internet gambling Casino card or table games Gabling with stock market or real estate No-casino card or table games Betting on games of skill Horse races Betting on outcomes of events Sports betting Other (please specify): Thank you for completing the Mamisarvik Application Form