Addiction Transitional Case Management Service (ATCM) Intake Form

Thank you for connecting with Addiction Services. Please note that filling out this intake form will take approximately 10-20 minutes and needs to be completed in full once you start. You are NOT able to save your work half way through. Once this form is completed, you will be directed to a second link to complete a short screener. This second form is a part of the intake process and need to be completed within 24 hours of this form. Once both forms are completed, an intake counsellor will call you within 2 business days to complete the process and get you connected with services.

BEFORE COMPLETING THIS INTAKE FORM PLEASE FOLLOW THE BELOW LINK TO ADDICTION SERVICES OF THAMES VALLEY'S CLIENT CONFIDENTIALITY FORM AND REVIEW IN FULL. http://adstv.on.ca/wp-content/uploads/2021/02/ADSTV-Client-Confidentiality-Form-Web-Version.pdf

Client Confidentiality - Consent Agreement:*

I clicked on the above link and have read and agree with the conditions of receiving services as outlined in confidentiality form. I understand that I will be given the opportunity to ask questions about the assessment and treatment process and any questions I have will be answered. Being aware of the conditions, expectations, risks, benefits, and process of assessment and treatment, I agree to participate in the services available to me at ADSTV. I understand that I can withdraw from services at any time.

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I have selected NO to providing consent to ADSTV's Client Confidentiality Policy. I understand that without providing that consent I cannot proceed with this online intake form submission and I will need to contact ADSTV's office directly to discuss:*

During business hours you can reach our reception desk directly by calling: 519-673-3242 ext. 222

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I am being referred by:*

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Date of Birth (Day/Month/Year)*

Message on Home Phone Ok?

Message on Work/Cell Phone ok?

Emergency Contact Name*

Emergency Contact Phone Number*

Message Ok for Emergency Contact?

Preferred Language of Service*

Which population/ethnicity best describes you:*

Asian – East (e.g. Chinese, Japanese, Korean)
Asian – South (e.g. Indian, Pakistani, Sri Lankan)
Asian – South East (e.g. Malaysian, Filipino, Vietnamese)
Black – African (e.g. Ghanaian, Kenyan, Somali)
Black – Caribbean (e.g. Barbadian, Jamaican)
Black – North American (e.g. Canadian, American)
First Nations
Indian – Caribbean (e.g. Guyanese with origins in India)
Indigenous/Aboriginal – not include elsewhere
Inuit
Latin American (e.g. Argentinean, Chilean, Salvadoran)
Metis
Middle Eastern (e.g. Egyptian, Iranian, Lebanese)
White – European (e.g. English, Italian, Portuguese, Russian)
White – North American (e.g. Canada, American)
Mixed heritage (e.g. Black – African & White – North American)
Other
Do not know
Prefer not to answer

ADMISSION INFORMATION

WHAT PROBLEM ARE YOU SEEKING HELP FOR*

PLEASE CHECK ALL THAT APPLY

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HOW READY ARE YOU TO MAKE CHANGES TO YOUR....*

NOT READY

UNSURE

READY

TREATMENT MANDATED BY*

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If Mandated by other:*

LEGAL STATUS*

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YOUNG OFFENDER*

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RELATIONSHIP STATUS*

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EMPLOYMENT STATUS*

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INCOME SOURCE*

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PARENTING:*

Are you parenting, pregnant, or caregiving a child under the age of 18?

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PRESENTING ISSUES AT ADMISSION

SUBSTANCE USE CONCERNS*

Yes

Check all substances used in the last 12months*

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GAMBLING CONCERNS*

Yes

Check all gambling activities you have engaged in during the last 12 months*

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If other gambling activity*

GAMING CONCERNS*

Yes

Check all gaming activities you have engaged in during the last 12 months*

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INTERNET/TECHNOLOGY CONCERNS*

Yes

Check all internet/technology activities you have engaged in during the last 12 months*

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Other internet activities*

SEX/PORNOGRAPHY CONCERNS*

Yes

Check all sex/pornography activities you have engaged in during the last 12 months*

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If other sex/pornography activities*

In the last 30 days which concerns have you had the most problem with?

I have the biggest problem with:*

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Gambling Activity*

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Gaming Activity*

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Internet/Technology Activity*

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Sex/pornography Activity*

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Biggest problem current use:*

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I have the 2nd biggest problem with:

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2nd biggest problem - Substance Use*

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2nd biggest problem - Gambling Activity*

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2nd biggest problem - Gaming Activity*

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2nd biggest problem - Internet/Technology Activity*

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2nd biggest problem - Sex/Pornography Activity*

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2nd biggest problem current use:*

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I have the 3rd biggest problem with:

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3rd biggest problem - Substance Use*

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3rd biggest problem - Gambling Activity*

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3rd biggest problem - Gaming Activity*

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3rd biggest problem - Internet/Technology*

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3rd biggest problem - Sex/Pornography*

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3rd biggest problem current use:*

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Do You Have a Primary Care Provider?*

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Primary Care Provider Name:*

Vision Impairment*

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Hearing Impairment*

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Mobility/Physical Impairment*

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Pregnant*

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Non-Medical Intravenous Drug Use*

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Have you ever shared injection equipment?*

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Number of Overnight Hospitalizations in the Last 12 months?*

In the last 12 Months Have You Been Diagnosed with a Mental Health Problem By a Qualified Mental Health Professional??*

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Within Your Lifetime Have You Even Been Diagnosed with a Mental Health Problem by a Qualified Mental Health Professional?*

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Within the Last 12 Months Have You Been Hospitalized for a Mental Health Problem?*

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Within Your Lifetime Have You Ever Been Hospitalized for a Mental Health Problem?*

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Are You Currently Receiving Counselling/Treatment/Support for a Mental Health, Emotional, Behavioural or Psychological Problem?*

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Within the Last 12 Months Have You Received Counselling/Treatment/Support for a Mental Health, Emotional, Behavioural or Psychological Problem?*

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Within Your Lifetime Have You Ever Received Counselling/Treatment/Support for a Mental Health, Emotional, Behavioural or Psychological Problem?*

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Are You Currently Being Prescribed Medication for a Mental Health Problem?*

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Within the Last 12 Months Have you Been Prescribed Medication for a Mental Health Problem?*

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Within Your Lifetime Have You Ever Been Prescribed Medication for a Mental Health Problem?*

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Have You Ever Had seizures?*

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Please List Any Other Health Problems:

(Examples: blood pressure, cancer, diabetes, heart problems, HIV/AIDS, Kidney disease, asthma, migraines, headaches etc.)

Do You Have Any Immediate Safety Concerns That You Would Life Assistance With Today Or Soon?*

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Have You Ever Had a Concerning Hit to Your Head, Been Hit on the Head and/or Experienced Multiple, Repeated Impacts to Your Head?*

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Have Your Ever Been in the Emergency Room, Hospital or Seen by a Doctor Because of an Injury to Your Head?*

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Did You Ever Lose Consciousness (including as a result of an overdose) Or Experience a Period of Being Dazed or Did You Have a Gap in Memory From The Injury?*

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Are You Currently Taking Anti-Craving Medication for Alcohol (Naltrexone)?*

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Are You Currently Taking Methadone/Suboxone?*

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Would you like to receive Naloxone Training?*

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Do You Require Support with Your Withdrawal Symptoms Today?*

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Would You Like a Call Back from the Community Withdrawal Support Program?*

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Have You Ever Attended Any Addiction Treatment Programs?*

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If yes please list below:*

Please follow this link to read Addiction Services of Thames Valley's Electronic Communication Policy:*

http://adstv.on.ca/wp-content/uploads/2021/02/Verbal-Consent-to-Electronic-Communication-Web-Version.pdf I have read the policy give permission for Addiction Services of Thames Valley to contact me via, phone, email and text. Please note: When contacted a staff member with further review this with you.

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I understand that this is only step one in completing/submitting my Intake Package for Addiction Services of Thames Valley. After submitting this form I understand that I will be redirected to a short screener that I must complete in order for my package to be complete.*

You are encouraged to complete your short screener the same day as this form. Should you need a break please ensure to submit within 24hrs.

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Send me a copy of my responses

CLIENT INFORMATION

ADMISSION INFORMATION

PRESENTING ISSUES AT ADMISSION

In the last 30 days which concerns have you had the most problem with?

HEALTH STATUS