First Nations Health Authority

Subsidy Application for Inpatient Addictions Treatment


Client Information

Client Residency Information

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

Chemical Use History

i) Substances Used - Select all that apply

ii) Use Pattern

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

Rationale for non-FNHA Funded Treatment Program

Have you done an assessment on your client?


Yes No

Yes No

If accessing family treatment, will children accompany client to centre

Yes No

Client Support Required Prior to Referral

Source of Referral

Name of Referral Worker

Name of Referring Organization

Mailing Address