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About Us
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History
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Recovery Starts Here
Recovery Starts Here
Adult Programs
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Donate Now
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Referral Form
Brentwood Recovery Home Referral Form
CLIENT INFORMATION
(Required)
Legal Name
Name
(Required)
First
Last
CLIENT OF DELEGATE CONTACT INFORMATION
Mother Tongue
Preferred offical language
(Required)
English
French
Preferred language to receive service:
(Required)
English
French
Other:
Other Language
Date of Birth:
(Required)
MM slash DD slash YYYY
Gender
(Required)
Male
Female
Non Binary
Trans Man
Trans Woman
Intersex
Two Spirit
Prefer not to say
I do not identify with any of these options
Unknown to staff
Health Card Information
(Required)
If Client does not have a valid Health Card, they will be required to obtain one prior to Intake
Version Code:
(Required)
Expiry Date
(Required)
MM slash DD slash YYYY
Client Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Contact information below is for the
(Required)
Client
Delegate
By listing the phone numbers or an email address below, the referral source confirms that the client consents for Brentwood to communicate with them via telephone and/or email regarding this referral. Brentwood will refrain from communicating personal information until consents are verified:
Delegate Information
If delegate please specify their name and relationship to client:
Type
(Required)
Phone #1
(Required)
Consent to voicemail message
(Required)
Yes
No
Type
Phone #2
Consent to voicemail message
Yes
No
Email
1. REFERRING PROVIDER INFORMATION:
(Required)
First
Last
Phone
(Required)
Fax
Email
(Required)
Insitution
(Required)
Please select one of the following:
(Required)
Physician
Psychiatrist
Nurse
Hospital
Detention Centre
Withdrawl Management
Self
Other
Other:
Reason for Referral:
(Required)
Please indicate the reason for the referral. Presenting issues and substance abuse history. (Substance used, amount of use, frequently, and last use).
2. SUBSTANCE USE: Is Client presenting with concurrent disorders?
(Required)
Yes
No
Please check all that apply:
substance use + mood and anxiety disorders, such as depression or panic disorder
substance use + severe and persistent mental health disorders, such as schizophrenia or bipolar disorder
substance use + personality disorders, such as borderline personality disorder, or problems related anger, impulsivity or aggression
substance use + eating disorders, such as anorexia nervosa or bulimia
other substance use + mental health disorders, such as gambling and sexual disorders.
3.RISKS AND SAFTEY CONCERNS
This information is used to determine the client’s suitability for treatment and to ensure their safety as well as the safety of all clients and Brentwood staff.
Deliberate Self Harm
(Required)
Yes
No
If Yes, When
Details
Violent Behaviour/Safety Concerns
(Required)
Yes
No
If Yes, When
Details
Legal Involvement
(Required)
Yes
No
If Yes, When
Details
Suicide Attempts/Ideation
(Required)
Yes
No
If Yes, When
Details
Cognitive Impairment
(Required)
Yes
No
If Yes, When
Details
Neurodiversity
(Required)
Yes
No
If Yes, When
Details
Accessibility concerns:
(Required)
Yes
No
If yes, please specify:
4. CONSULTATION NOTES
(Required)
Completed by:
(Required)
(Print name & Credentials)
Date
(Required)
MM slash DD slash YYYY
Please feel free to upload any document that may be useful
Drop files here or
Select files
Max. file size: 2 GB.
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