8 Pillars Recovery Foundation
8 Pillars Recovery Foundation
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Admissions Application
Your Personal Information
Your Legal Name
(Required)
First
Middle
Last
Chosen Name (if different from legal name)
First
Middle
Last
Your Email Address
Enter Email
Confirm Email
Your Phone
Best Time To Call You
When is the best time for us to reach you via telephone?
Mornings
Early Afternoon
Late Afternoon
Early Evening
Gender
(Required)
Female
Male
Non-Binary
Genderfluid
Other
Pronouns
What pronouns do you use?
She/Her
He/Him
They/Them
It/Its
Other
Date of Birth
(Required)
YYYY dash MM dash DD
Alberta Health Care Number
Are you First Nations?
Yes
No
How do you identify culturally?
First Nations
Métis
Inuit
Status Number
Are you currently unhoused?
Yes
No
Are you involved in the recovery community?
Yes
No
Other
Please list any substances you have used in the past.
What is your Drug-Of-Choice (DOC)?
Past Treatment Centres (if any) (please include dates attended, name of treatment centres, and whether or not you completed the program)
Clean Date/Sobriety Date
YYYY dash MM dash DD
Employment Status
Employed
Unemployed and Looking
Unemployed and Not Looking
I Will Not Be Seeking Employment
Are you on income support?
Yes
No
Income Support Type
AISH
Alberta Works
Other
Income Support File Number
AISH File Number
Net Income (Monthly)
Current Medications (with dosages if possible)
Healthcare Information
Family Doctor's Name
Family Doctor's Phone Number
Pharmacy Used
Pharmacy Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Pharmacy Phone
Pharmacy Fax
Please list any mental health diagnoses.
Other Needs/Special Needs
Legal
Do you have a criminal record?
Yes
No
Have you committed a sexual offence?
Yes
No
Parole or Probation Officer's Name
First
Last
Parole or Probation Officer's Phone
Parole or Probation Officer's Email
Support
Emergency Contact Name
First
Last
Emergency Contact's Phone
Emergency Contact's Email
Referring Agency (self if self-referring)
More About You
More Details
Consent
(Required)
I agree to the terms and conditions and assert that all the information entered is true to the best of my ability.
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