Lakeview Admission Application Form

We understand that seeking help is a significant and courageous step, whether for yourself, a client or patient, or a family member. Our team is committed to providing a supportive, confidential, and compassionate admissions process for all individuals who are ready to embark on their recovery journey.

Who Can Refer?

Self-Referral: If you feel that you need support in overcoming addiction or other challenges, you can directly apply yourself.
Professional Referral: Healthcare providers, counselors, social workers, and other professionals can refer their clients or patients who may benefit from our services.
Family Referral: Family members concerned about their loved one's well-being can also submit a referral on their behalf.

Confidentiality Assurance

We prioritize your privacy and are committed to maintaining the confidentiality of all applicants. Rest assured that any information you provide during this process will be handled with the utmost care and discretion, adhering to all relevant privacy laws and standards.

Person filling out the form:

If someone other than the subject is filling out this form, please provide the following details:

Your Full Name:

Your relationship to the Subject:

Your Phone:

Your Email Address:

Applicant Information

Full Name:

Birthday

Gender:

Address:

City:

Postal Code

Country

Phone:

Email:

Preferred Method of Contact:

Phone

Alberta Care Card Number:

Emergency Contact Information

Contact Name:

Relationship:

Phone:

Alternate Contact Name:

Relationship:

Phone:

Current Housing Status

Housed

Unhoused

Transitional Housing

Location:

Shelter

Location:

Couch Surfing

Location:

Detox

Location:

Treatment

Location:

Theraputic Living Unit

Location:

Recovery House

Location:

Recovery Community

Location:

Hospital

Location:

Other

Please Specify:

Corrections Involvement

Are you currently involved with Corrections?

Yes

If yes, please specify:

Remand

Sentenced Pending Release

Drug Court

Parole

Other

Please Specify

Additional Details

Probation Officer Name:

Probation Officer Contact:

Next Court Date:

Charges/Offenses:

Current Legal Representation:

Lawyers Name:

Lawyer's Contact Information:

Do you have a criminal record

Yes

If yes, please list charges/offenses:

Basic Medical Information

Do you have any chronic medical conditions?

Yes

If yes, please list:

Are you currently taking any medications?

Yes

If yes, please list:

Substance Use History

Primary Substance of Use - Frequency of Use:

Secondary Substance of Use - Frequency of Use:

Previous Treatment History

Have you attended a treatment program before?

Yes

If yes, please list:

Consent and Agreement

I, certify that the information provided is true and complete to the best of my knowledge. I understand that providing false information may result in my application being denied

Lakeview Admission Application Form

Who Can Refer?

Confidentiality Assurance

Person filling out the form:

Applicant Information

Emergency Contact Information

Corrections Involvement

Additional Details

Basic Medical Information

Substance Use History

Previous Treatment History

Consent and Agreement

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