Start on the road to recovery today

Application Form

Top of the world treatment centre

Online Admission Form

- Step 1 of 8

Even if you do not have insurance, you may still be able to pay nothing to attend treatment.

Information we collect via this submission form is secure and confidential. We will not share any of your protected health information without your consent.

COVID-19 Screening

Have you recently traveled outside of your immediate surroundings, to another city, state/province, or country? *

Have you recently been around anyone who has tested positive for COVID-19, or exhibited symptoms of COVID-19?* *

Are you experiencing shortness of breath? *

Are you experiencing a cough? *

Are you experiencing joint pain? *

Have you been tested for COVID-19?* *

When were you tested? *

What were your results? *

Demographics

Client Name *

First

Last

Date of Birth *

Alias or "AKA" (Write N/A if not applicable.) *

Phone Number *

Alternate Phone Number

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

May we leave a message? *

What time works best? *

Filling out on behalf of you or someone else? *

For myself
On behalf

If "For Myself", Will you allow us to speak with someone regarding admission to the Ranch?

Please list name and contact info of person. *

Emergency Contact Information

Emergency Contact *

Relationship to Client *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Personal Information

Height *

Weight *

Eye Color *

Hair Color *

Tattoos *

Religious/Spiritual Affiliation (Write N/A if not applicable.) *

Identifying Features *

Insurance Information

Do you have insurance? *

Name of Insurer *

Member ID Number *

Group Number *

Phone Number for Member Services *

Phone Number for Behavioural health (Write N/A if not applicable.) *

Current Employment (Write N/A if not applicable.) *

If treatment will impact your employment please explain (Write N/A if not applicable.) *

History of Violence *

Please Explain *

Pending Court Date *

When? *

Please Explain *

Outstanding Warrants *

Please Explain *

Probation *

Please Explain *

Parole *

Please Explain *

Other Legal *

Please Explain *

Please explain in detail (please include any potential court involvement that might impact your stay in treatment)

Substance Use History

Alcohol

Ever Used Alcohol? *

Are you currently using this substance? *

What type of alcohol do you consume? *

Date of Last Use *

Duration of use? *

How much? *

How often? *

Have you tried to stop *

History of Withdrawal Seizures *

Have you ever consumed non-beverage alcohol, such as hand sanitizer, antifreeze, cologne, etc.? *

Please describe what, how often, first and last use. *

What are your drinking habits or patterns (e.g., daily, weekends)? And, how has that evolved since your first use? *

In the past when you tried to stop drinking, what happened? *

Please describe what your withdrawal was like. *

Did you experience any of the following withdrawal symptoms? *

Dehydration
Sweats
Anxiety
Fear
Seizures
Hallucinations
Delirium Tremens
Pneumonia
N/A

Marijuana/Hash, etc. (include medical marijuana) Please specify:

Ever Used Marijuana/Hash *

Are you currently using this substance? *

Date of Last Use *

Duration of use? *

How Much? *

How Often? *

Tried to stop? *

History of withdrawal? *

Opioids (Heroin, Morphine, Dilaudid, Oxycontin/oxycodone, Fentanyl, etc.). Please specify

Ever Used Opioids? *

Are you currently using this substance? *

Date of Last Use *

Duration of use? *

How Much? *

How Often? *

Tried to stop? *

History of withdrawal? *

Is the client presently on any drug or opiate replacement therapy (DRT/ORT)? *

Which therapy? *

Methadone
Suboxone

How long have they been prescribed this? *

Current Dosage *

Impact on Alertness *

Do you wish to use an opiate replacement therapy? *

I have been informed of and agree to schedule an aftercare appointment for DRT/ORT while in treatment here?* *

If client has been using opiates prior to coming to treatment (usually within past month), they are aware that they will be admitted to detox for a period of assessment. *

If client is on an opioid other than DRT/ORT, our policy and practice is to taper clients off of opioids. Is client willing to work with the Ranch doctor to taper off of any opioids? *

Amphetamines (e.g., Crystal Meth, Dexedrine, Adderall, etc.) Please specify:

Ever Used Amphetamines *

Are you currently using this substance? *

Date of Last Use *

Duration of use? *

How Much? *

How Often? *

Have you tried to stop? *

History of withdrawal? *

Method of use? *

Were any amphetamines prescribed to you by a physician? *

Have you ever misused or abused these medications (amphetamines) as prescribed? *

Please Explain *

Substance Use History Continued...

Ever Used Cocaine/Crack *

Are you currently using this substance? *

Date of Last Use *

Duration of use? *

How Much? *

How Often? *

Have you tried to stop? *

History of withdrawal? *

Method of use? *

Hallucinogens (e.g., Mushrooms, LSD, Salvia, etc.) Please specify:

Ever used Hallucinogens? *

Are you currently using this substance? *

Date of Last Use *

Duration of use? *

How Much? *

How Often? *

Have you tried to stop? *

History of withdrawal? *

Club Drugs (e.g., Ecstasy, Ketamine, GHB, etc.) Please specify:

Ever used Club drugs? *

Are you currently using this substance? *

Date of Last Use *

Duration of use? *

How Much? *

How Often? *

Have you tried to stop? *

History of withdrawal? *

Method of use? *

Benzodiazepines (e.g., Valium, Ativan, Xanax, Clonazepam, etc.) Please specify:

Ever used Benzodiazepines *

Are you currently using this substance? *

Date of Last Use *

Duration of use? *

How Much? *

How Often? *

Have you tried to stop? *

History of withdrawal? *

Method of use? *

Were these medications (benzodiazepines) prescribed to you? *

Have you ever misused or abused these prescribed medications (benzodiazepines)? In other words have you taken them in a way that was not prescribed? *

Please Explain *

How long have you been taking these medications (benzodiazepines)? *

If your client is on benzodiazepines, our policy and practice is to taper clients off of benzodiazepines. Is client willing to work with the Ranch doctor to taper off of any benzodiazepines? *

Tobacco (e.g., cigarettes, chewing tobacco). Please specify:

You are permitted to use tobacco while attending treatment at the Ranch

Ever used Tobacco? *

Date of First Use *

Are you currently using this substance? *

Date of Last Use *

Duration of use? *

How Much? *

How Often? *

Quantity (Per Day): *

Have you tried to stop? *

History of withdrawl? *

Would you like to stop? *

Other Addictive Behaviours:

Shopping? *

Sex/Pornography? *

Love/Relationships? *

Eating? *

Gambling? *

Excessive Work? *

Excessive Exercise? *

Emotional Eating? *

Gaming? *

Do you have other addictive behavior(s)? *

If “Yes” to Other Addictive Behavior(s), please provide examples: *

Do you or others see any of the behaviors as negatively impacting your life? Such as relationships or work? *

Primary Care Provider *

Name of Primary Care Provider *

Psychiatrist/Mental Health Provider *

Name of Psychiatrist/Mental Health Provider *

Are you Diabetic? *

What type? *

Type 1
Type 2
N/A

Diabetes well and consistently managed? *

Insulin dependent? *

Medication? *

Insulin pump? *

Gastrointestinal Issues? *

Please Explain *

Celiac Disease? *

Please Explain *

Potentially Pregnant? *

Please Explain *

Colitis? *

Please Explain *

Pancreatitis? *

Please Explain *

Irritable Bowel Syndrome (IBS) *

Please Explain *

Migraines? *

Please Explain *

Liver Failure or low function? *

Please Explain *

Cirrhosis? *

Hepatitis? *

Hep B
Hep C
N/A

Other Chronic Medical Conditions? *

Please Explain *

Heart Failure? Heart Condition? *

Please Explain *

Acquired Brain injury? *

Please Explain *

Chronic Pain? *

Please Explain *

Mobility Issues? *

Please Explain *

Learning Disability? *

Please Explain *

Injuries/Accidents *

Please Explain *

Epilepsy/Seizure Disorder *

Please Explain *

Any other disabilities that would limit full participation in program? *

If yes, list disabilities: *

Have you been diagnosed with insomnia or other sleep disorder, such as sleep apnea? *

Please Explain *

Hospitalization (non-psychiatric or detoxification): *

If yes to hospitalizations, list dates and reasons for: *

Are you currently having suicidal thoughts? *

National Suicide Prevention Lifeline: *

If you or someone you love is having suicidal thoughts please call 800-273-8255. You are not alone and there are people to talk to. If you have experienced or are experiencing suicidal thoughts, the National Suicide Prevention Lifeline is available to you 24/7 at 1-800-273-8255. If you are in need of emergency medical attention, please call 911 or your nearest emergency room.

Have you had suicidal thoughts in the last 3 months? *

Please Explain *

Have you ever had suicidal thoughts? *

Please Explain *

Have you ever attempted suicide? *

Please Explain *

Did you require any medical attention, such as an Emergency Room Hospital visit? (Excluding psychiatric inpatient services/hospitalizations) *

Please Explain *

Do you currently engage in self-harm behavior? *

Please Explain *

Have you engage in self-harm in the past 3 months?* *

Please Explain *

Were you using alcohol or drugs at the time of the self-harm? *

Please Explain *

Did you require any medical attention, such as an Emergency Hospital visit? (Excluding psychiatric inpatient services/hospitalizations) *

Please Explain *

Medications, Vitamins and Supplements (All Prescribed and Over the Counter) Please give a detailed list of your current medications. (Write N/A if not applicable.)

Medication Name / Dosage(mg) / How Often? / Time of Day Taken / Is it PRN(As Needed)? / Why do you take this medication?

Please read the following: “For safety reasons, all over the counter medications or herbal supplements must be approved for use by our Ranch Physician. Please limit all supplements to those that you feel are NEEDED rather than DESIRED. Unless there is a medically necessary reason stated by a licensed physician, we will limit the number of herbal supplements to 4 (four). We will require a medical note.” I have read and understand the above requirement. *

If you require further explanation of the above, please do not hesitate to ask Ranch staff prior to attending treatment.

Client`s Home/Local Pharmacy Name* *

Pharmacy Phone # *

Pharmacy Location: *

Food Allergies *

If "Yes", Please list food allergies *

Drug Allergies *

If "Yes", Please list drug allergies *

Any other Allergies *

If "Yes", Please list other allergies. *

Please describe any Dietary Restrictions we should know about? (i.e., Vegetarian/Vegan/Lactose Intolerant/ Sodium Controlled Diet): (Write N/A if not applicable.) *

Please describe any dietary or religious restrictions we should be aware of: (Write N/A if not applicable.) *

Chronic cough(+2 weeks) *

Please Explain *

First Nations AND on Reserve *

Please Explain *

Productive Cough (mucus/phlegm) *

Please Explain *

Exposure to TB *

Please Explain *

Bloody Sputum(hemoptysis) *

Please Explain *

Previous Active TB with Treatment *

Please Explain *

Rapid Weight Loss *

Please Explain *

Positive Mantoux (TB) Test / CXR *

Please Explain *

Night Sweats *

Please Explain *

History of Birth/Travel to Countries with high incidence of TB *

Please Explain *

Fever (often low grade) *

Please Explain *

History of Correctional Institution or Long-Term Care Facility *

Please Explain *

Feelings of Fatigue *

Please Explain *

History of Intravenous Drug Use / IV Substance Use: *

Please Explain *

Fully Immunized *

Please Explain *

Have you ever had an adverse reaction to a vaccine? *

Please Explain *

Immunized as a child *

Please Explain *

Immunized through work *

Please Explain *

Immunized for travel *

Please Explain *

Did you receive the Flu vaccine this year? *

Please Explain *

Are you interested in receiving the Flu vaccine? *

Please Explain *

Intensive Residential Treatment Readiness

Have you ever been formally diagnosed by a mental health professional with a Mental Health Disorder or Concurrent Disorders?

If “Yes,” please list your diagnosis and approximate date of diagnosis: *

Do you have any concerns about: Feeling depressed, sad, lacking energy or lacking enjoyment in life? *

Feeling nervous, anxious or agitated? *

Quality of, or amount of sleep? *

Have you ever been hospitalized for psychiatric reasons? *

Please explain: *

If hospitalized previously, list how many times and the dates: (Write N/A if not applicable.) *

Anorexia *

Is this current or past? *

Is this only present while you are actively using? *

Bulimia: *

Is this current or past? *

Is this only present while you are actively using? *

Any binge or purge eating behaviors that do not meet criteria for an Eating Disorder? *

Have you experienced any physical abuse or trauma? (Answer ONLY YES OR NO): *

Counseling History

Have you received counseling, psychological or psychiatric services in the past? *

How long ago? *

For How Long? *

What were your goals while you attended and what was most helpful? *

Previous Substance Abuse Treatment Experience

Have you ever entered any addiction treatment programs in the past? *

Did you complete the program? *

If "No", explain? *

Dates (Write N/A if not applicable.) *

Name of treatment Progam(s): (Write N/A if not applicable.) *

What were your goals while you attended and what was most helpful? (Write N/A if not applicable.) *

Client Readiness to Change Questions

What are your personal goals for treatment here at the Ranch? What changes do you want to make in your life? *

On a scale of 1 to 10 (1 being not at all and 10 being extremely), how important is it to you that you make these changes? *

Please enter a number from 0 to 10.

On a scale of 1 to 10 (1 being not at all and 10 being extremely), how confident are you that you can make these changes? *

Please enter a number from 0 to 10.

What do you feel may be challenges during your stay at treatment? *

How can we work with you to minimize these challenges? *

Referral Source

How did you hear about us? *

Please choose one of the following referral sources*

Self-Referral
Family Member
Counselor
Doctor
Employer
Alumni
Other

If "Other" is chosen write down the referral source *

Name of referring individual? (Write N/A if not applicable.) *

Phone number? (Write N/A if not applicable.) *

Contact information for referral source? (Write N/A if not applicable.) *

Describe any previous involvement with Alcoholics Anonymous, Refuge, Narcotics Anonymous, SMART, etc. (Write N/A if not applicable.) *

If neccessary, is there anything else beneficial for us to know? *

Write N/A if not applicable.

I acknowledge that I am committed to stay a minimum of 30 days of treatment. *

We find that people do best in treatment when they limit connection with the outside world while in treatment. We do conduct family sessions while you're here via telehealth. There is a phone that can be accessed after the first 7 days of treatment. During the first 7 days of treatment there is no phone access unless for emergencies. We encourage you to leave your electronic devices at home. Is there any reason you would need to bring an electronic device to treatment or need to use a device outside of the phone that is accessible when you are not participating in programming hours after the first 7 days of treatment? *

If "Yes", please explain (write "N/A" if "No"): *

I acknowledge that due to COVID-19 we are not allowing visitors on site, and Ranch clients can complete video conferencing with family members through counseling sessions following the first 7 days of treatment. *

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Start on the road to recovery today

Application Form

Top of the world treatment centre

Online Admission Form

COVID-19 Screening

Demographics

Emergency Contact Information

Personal Information

Insurance Information

Substance Use History

Alcohol

Marijuana/Hash, etc. (include medical marijuana) Please specify:

Opioids (Heroin, Morphine, Dilaudid, Oxycontin/oxycodone, Fentanyl, etc.). Please specify

Amphetamines (e.g., Crystal Meth, Dexedrine, Adderall, etc.) Please specify:

Substance Use History Continued...

Hallucinogens (e.g., Mushrooms, LSD, Salvia, etc.) Please specify:

Club Drugs (e.g., Ecstasy, Ketamine, GHB, etc.) Please specify:

Benzodiazepines (e.g., Valium, Ativan, Xanax, Clonazepam, etc.) Please specify:

Tobacco (e.g., cigarettes, chewing tobacco). Please specify:

Other Addictive Behaviours:

Intensive Residential Treatment Readiness

Counseling History

Previous Substance Abuse Treatment Experience

Client Readiness to Change Questions

Referral Source

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