Intake Form – Surrey

    Personal Information

    If Other, please specify:
    If First Nations Status:

    Referral Information

    If you answered ‘Yes’ to any of the above:

    Reasons for attending our program

    Intake Background Questions

    1. Marital Status:

    2. Dependents: (enter number)

    3. Employment Status:

    4. Education Level:

    Other Education:

    5. Substance Misuse:

    6. Do you misuse more than one substance on a regular basis?

    7. Are you challenged with:

    8. Do you have a history of suicidal ideations?

    9. Do you currently have suicidal ideations?

    10. Have you been diagnosed with Schizophrenia, BPD, Anorexia, Bulimia, PTSD, BP, Clinical Depression?

    Statement of Client Confidentiality & Consent for Release & Exchange of Information

    The information you will give will be created with strict confidentiality according to the law of B.C Freedom of Information and Protection of Privacy Act.

    The NCCBAC’s Indigenous Outpatient Addictions Counselling and Detox Support Programs may need to release certain information about individuals to another agency, especially for collaboration for referrals. lf so, only the agency and contact person in the table below will be contacted.

    All information you supply is voluntary. You will not be refused service if you choose not to supply all information requested. However, you have a responsibility to be a part of your own evaluation process, and this begins by talking openly and honestly with the NCCABC program personnel .The outpatient staff work as a team therefore we do consult with each other about clients.

    The NCCABC’s Indigenous Outpatient Addictions Counselling and Detox Support Programs will provide reports to the funder Vancouver Coastal Health’s Aboriginal Health. The of the manager of the programs will request your written permission to utilize your program testimonial as a submission for funding purposes only.

    Please discuss any questions you have concerning confidentiality with A & D staff. We can further explain your rights regarding the information you give to the program, if necessary.

    understand that all information gathered by NCCABC programs is considered confidential and will only be shared outside the NCCABC’s program, if I have given my written permission.

    I also understand that is some situations information about me may be disclosed because it is our policy or is legally required. Information could be released without written permission in the following circumstances:

    – Communication with health care professionals
    – Communication with a Treatment Center
    – Complying with a subpoena
    – Responding to a threat of harm to self or others
    – Reporting of suspected child abuse
    – Responding to a medical emergency

    Additional Notes:

    I hereby authorize the following agencies/people to be contacted for the purpose of releasing information to assist in my service needs:

    The Native Courtworker & Counselling Association of British Columbia
    NCCABC Personnel | Phone: 604-628-1143

    This agreement is valid for one year from where it is initialed and dated above:

    I read and accepted the terms and policies for Confidentiality & Consent for Release form above.