Referring Agency | Lakeview

Are you an Alberta resident, and do you have an active Alberta Health number?

Yes

Alberta Health Number

9 characters left

In order to attend Lakeview Recovery Community you must be an Alberta resident with an active Alberta Health Number. Please email admissions at admissions@lakeviewrc.ca for more information.

Applicant Name

Applicant Phone Number

Applicant Birthday

Date

Staff Name

Referral Source

Section 1: Consent & Disclosure

I understand that this is a preliminary assessment to determine eligibility for admission.
I agree to provide honest and complete information to the best of my ability.

Staff Initials

Section 2: Substance Use History

Other:

1. What substances are you currently using?

3. Date of last use:

Date

4. Typical amount used:

5. History of overdose?

Yes

If yes, last overdose date:

6. History of withdrawal symptoms?

Yes

If yes, describe (e.g., seizures, DTs):

Section 3: Medical History

1. Do you have any current or past medical conditions?

Yes

If yes, please list:

2. Any history of:

3. Most recent Hospitalization:

Date

Length of stay:

Reason for Hospitalization:

Outcome:

4. Do you have any mobility issues?

Yes

If yes, please list:

5. Do you have any diagnosed medical disabilities?

Yes

If yes, please list:

6. Do you have any allergies?

Yes

If yes, please list:

7. Are you currently under a doctor’s care?

Yes

If yes, please provide Doctor's info:

8. Any communicable diseases we should be aware of? (e.g., Hepatitis, HIV)

Yes

If yes, please list:

9. Current medications and length of time on medication (include dosage if known):

10. Are you taking medications as prescribed?

Yes

Section 4: Mental Health & Medications

1. Have you ever been diagnosed with a mental health condition?

Yes

Other

2. Are you currently taking any medications prescribed to support this diagnosis?

Yes

If so, how long have you been on this medication and dose?

How consistent are you with taking this medication?

3. How would you describe your mental health over the past 2 - 4 weeks?

4. Have you experienced panic attacks, racing thoughts, paranoia, or hallucinations recently?

5. Have you ever experienced periods of hallucinations (Visual or Auditory) or feeling unsafe when others say you are safe?

6. How do you usually cope when you feel stressed or overwhelmed?

7. Any history of:

Suicide attempts:

Yes

If yes, please provide timeline:

Self-harm:

Yes

If yes, please provide timeline:

8. Are you currently experiencing:

Suicidal thoughts:

Yes

If yes, please explain:

Psychosis (hallucinations/delusions):

Yes

If yes, please explain:

9. Have you had any recent thoughts about hurting someone else?

Section 5: Living Situation

Other:

2. Is your current environment safe and substance-free?

Yes

3. Do you have reliable transportation to the facility?

Yes

Section 6: Criminal History

1. Do you have any current or past criminal charges?

Yes

If yes, please describe:

3. Any history of violent or sexual offences?

Yes

Details:

4. Have you ever been charged with arson?

Yes

Details:

5. Warrants and Court Dates

Any outstanding warrants or upcoming court dates?

Yes

Details:

Are you required to attend in person?

Yes

Details:

Important Disclosure Statement

Failure to disclose relevant information—including substance use, medical conditions, mental health diagnoses, medications, or criminal history—may result in denial of admission or discharge from the program if discovered after acceptance.

Client Signature

Date

Notes:

Lakeview Recovery Community Referring Agency Form

Section 1: Consent & Disclosure

Section 2: Substance Use History

Section 3: Medical History

Section 4: Mental Health & Medications

Section 5: Living Situation

Section 6: Criminal History

Important Disclosure Statement