Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Hair colour
Eye colour
Gender
Birthplace
*
Date of Birth
MM
DD
YYYY
SIN #
*
Personal Health #
*
Emergency Contact name
*
Emergency contact phone #
*
Emergency contact location
*
Where are you living right now?
*
How long have you been living there?
*
If you are currently homeless: what is the extent of your homelessness?
Reason(s) for current situation
*
Check all that apply
If you checked bedbugs / other infestations: what kind / how long ago?
Are you a domestic violence victim?
*
If you answered yes:
Extent of domestic violence
Sources of income
Are you employed?
*
If you are employed: Where do you work, and how much do you earn?
Education
*
Are you in school or working on a certificate or degree?
*
If yes: please explain:
Are you a registered sex offender?
*
Have you ever been charged or convicted of a sexual offence?
*
Do you have any legal charges against you?
*
If yes: what are you charged with?
Are you currently on probation?
*
If yes: what are you on probation for?
If applicable: probation / parole officer name
If applicable: probation / parole officer phone #
Are you aware of any outstanding warrants for your arrest?
*
If yes: what are the nature of the charges?
My overall health is:
*
Are you pregnant?
*
If pregnant: list due date
MM
DD
YYYY
List any drug misuse you are currently experiencing
List any alcohol misuse you are currently experiencing
Process addictions
Check all that apply
If other: please specify
Please indicate any medical issues you are currently dealing with, and list any related medications or treatment you are taking.
Please indicate any mental health issues you are currently dealing with
If other: please specify
If applicable: What medication(s) are you currently taking for mental health related issues?
Please list all health care providers you are working with (NAME / PHONE / DATE OF LAST VISIT)
Family doctor, psychologist, counsellor, psychiatrist, pharmacist, social worker, etc.
Briefly tell us about your treatment history
*
Briefly tell us about your treatment goals
*
I consent to the collection and disclosure of my personal information, including information about my medical, mental health and legal information for the purposes of determining my suitability for RAN Mission’s residential and recovery program(s) and for planning and managing my stay.
*
RAN Mission in Chilliwack BC is a full-range service provider to support those struggling with poverty, homelessness and addiction by bringing hope and healing through the love of God. Our program and services are unapologetically spiritually-based. In this, we believe that meaningful life-change is best accomplished through a relationship with Jesus Christ. We blend biblical principles with proven life-support strategies to assist clients in pursuing their goals. We welcome those of any faith or those of no faith to come and be part of our program but we do ask that while you are with us in the program that you be supportive of our spiritual values and the work we do which are based upon Christian principles.
*
I affirm that the above information is true and complete to the best of my knowledge. I understand that if any of the above information is materially false, I may be expelled from the Residential Addiction Treatment Services at RAN Mission.
*
