Application - Clear Hills Youth Treatment Centre

Eligibility for youth treatment services provided through Indigenous Services Cananda are below:

Are registered or eligible to be registered under the Indian Act
Have one parent or guardian who is registered or eligible to be registered under the Indian Act
Are recognized by their Nation
Are ordinarily resident on reserve

If you'd prefer to fill the form out off-line rather than online, please download a physical copy of the intake form or medical assessment form below.

NOTE: The medical form must be printed out and filled out by a doctor.

Download Referral Form Download Medical Form Sign Your PDF Online

Client Information

First Name*

Nickname/Other Name Known By

Last Name*

Date of Birth*

Age*

Sex*

Gender*

Provincial Health Card Number*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Living Situation*

Phone*

Language Spoken*

Language Preferred*

Language Understood*

Status Indian

Yes

No

Treaty Number

Band Name

Parental/Guardian Information

Biological Parents

Please enter the name(s) of your biological parents.

Guardian Names

Please enter the name(s) of your guardian(s).

Guardian(s) Address

Street Address City State / Province / Region ZIP / Postal Code

Proof of Guardianship (ie: Court appointed documents, birth certificate)

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, docx, doc, Max. file size: 8 MB.

Guardian Phone

Guardian Email

Employment Information

Place of Employment

Employer Phone

Social Services Involvement

Agency Name

Phone Number

Worker Name

Client Status

Child Welfare Involvement

Yes

No

Unknown

Education

Does your client go to school?

Yes

No

Unknown

Does your client like school?

Yes

No

This field is hidden when viewing the form

Highest grade completed

Name of school

Last year attending this school

Medical History

Does your client have any medical problems?

Yes

No

Please identify

Does he/she require a medical consent form?

Yes

No

Family doctor's name

Family doctor's phone number

Is your client currently on any medication?

Yes

No

Does he/she have any allergies?

Yes

No

Application for the Clear Hills Youth Treatment Centre

Eligibility for youth treatment services provided through Indigenous Services Cananda are below:

Client Information

Parental/Guardian Information

Employment Information

Social Services Involvement

Family/Relationships

Provide information on client's children or other dependants.

Sibling Information

Other Relationships

Other

Education

Medical History

Legal Problems

Probation/Court order information

Probation Order

Chemical use history

Where does your client sniff or huff

Previous treatment information

Psychological functioning

Outside Resources

Medical Assessment

A. Medical History (explain any 'yes' responses in section B)

Head Office

Sub Office

Contact

Land Acknowledgement