First Nations Health Authority

Client Information

• First Name^ⓘ
• Middle Name
• Last Name

• Gender^ⓘ
• Date of Birth^ⓘ
• Status No^ⓘ

• FNHA Region^ⓘ
• Band Name^ⓘ

• Employment Status^ⓘ

Client Residency Information

Has the client been a BC resident in the last 3 months?

• Yes^ⓘ
• No^ⓘ

• On Reserve^ⓘ
• Off Reserve^ⓘ

• Street #^ⓘ
• Street Name
• Town
• Province
• Postal Code

Chemical Use History

i) Substances Used - Select all that apply^ⓘ

• Alcohol

• Street Drugs

• Prescription Drugs

• Inhalants

• Opioids

ii) Use Pattern^ⓘ

Previous Treatment: List all in-patient treatment received in previous 2 years

• Name of Centre^ⓘ
• Date Attended^ⓘ
• Treatment Completed^ⓘ

• Yes^ⓘ No^ⓘ

• Yes No

• Yes No

Rationale for non-FNHA Funded Treatment Program

Have you done an assessment on your client?^ⓘ

Have you developed a treatment plan for your client?^ⓘ

Reason for Referral^ⓘ

Name of non-FNHA Funded Treatment Centre^ⓘ

Mailing Address:^ⓘ

• Street #
• Street Name
• Town
• Province
• Postal Code

Contact^ⓘ

• Phone
• Fax
• Email

If accessing family treatment, will children accompany client to centre

Client Support Required Prior to Referral

Counsellor Support

# of Counselling Sessions Recieved Prior to Referral Support

Cultural Support

Self-Help Groups

Others

Source of Referral

Name of Referral Worker^ⓘ

• First name
• Last name
• Contact Phone^ⓘ
• Fax
• Email

Name of Referring Organization^ⓘ

• Region
• Referring Organization

Mailing Address

• Street #
• Street Name
• Town
• Province
• Postal Code