• Home
  • About Us
  • Application
  • Careers
  • Contact Us
Intake Form

Application for the Clear Hills Youth Treatment Centre

If you’d like to come to the Clear Hills Youth Treatment Centre, please fill out the Intake Form below.

"*" indicates required fields

Step 1 of 10

10%

Note: 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

Client Information

Address*
Living Situation*
Status Indian

Parental/Guardian Information

Please enter the name(s) of your biological parents.
Please enter the name(s) of your guardian(s).
Guardian(s) Address
Drop files here or
Accepted file types: pdf, jpg, jpeg, png, docx, doc, Max. file size: 8 MB.

    Employment Information

    Social Services Involvement

    Client Status
    Child Welfare Involvement

    Family/Relationships

    Does the client have dependant children?
    If yes, do they have access to adequate childcare while in treatment?
    Are the children in care?
    Does the client have other dependants?

    Provide information on client's children or other dependants.

    Who does your client live with?
    This field is hidden when viewing the form
    How does your client get along with his/her family members?
    Does client have any siblings?

    Sibling Information

    Other Relationships

    Does your client have any close friends?
    Does he/she have a girlfriend or boyfriend?
    Is he/she sexually active?
    Does he/she talk to any elders?
    Is he/she willing to listen?
    Religious beliefs

    Other

    Education

    Does your client go to school?
    Does your client like school?
    This field is hidden when viewing the form

    Medical History

    Does your client have any medical problems?
    Does he/she require a medical consent form?
    Is your client currently on any medication?
    Does he/she have any allergies?

    Legal Problems

    Has your client ever been in trouble with the law?
    Gang involvement
    Was alcohol or any other substances; such as `sniff` or drugs involved during your client`s legal problems?
    Is your client currently on probation or on a court order?

    Probation/Court order information

    Probation Order

    Start date
    End date
    Copy attached?
    Drop files here or
    Accepted file types: jpeg, jpg, gif, png, pdf, dox, docx, Max. file size: 2 MB.

      Chemical use history

      Has your client been involved with any Solvents/Substance Abuse?

      Does anyone else in his/her family use solvents/substances?
      Does your client usually sniff or huff at home?

      Where does your client sniff or huff

      Does your client usually sniff or huff at a friend's house?
      Does your client usually sniff or huff at school?
      Does your client usually sniff or huff in an abandoned building?
      Does your client usually sniff or huff in an abandoned car or truck?
      Does your client usually sniff or huff at a party?
      Does your client usually sniff or huff outdoors?
      Has your client ever lost friends because of sniffing or huffing?
      Has your client ever gotten into any physical fights when using?
      Has your client ever caused serious injury to other?
      Does the client have any medical, physical, psychological, emotional problems because of the use of solvents/substances?
      Does he/she feel that they have control over their use of solvents/substances?
      Has he/she ever considered reducing or quitting?
      Has he/she ever been in any previous treatment for their use of solvents/substances?

      Previous treatment information

      Has client participated in a non-residential/community based substance abuse and/or mental health program?

      Psychological functioning

      Has your client ever spoken or written about killing him/her self?
      Has your client ever attempted to kill him/her self?

      Has the client frequently gone off on their own when he/she is depressed or unhappy?
      Is the client sad/unhappy?
      Self harming behaviour(s)
      Is there any known history of sexual abuse?
      Is there any known history of physical abuse?
      Is there any known history of emotional abuse?
      Is there any history of family violence that this child may have been witness to?
      Are these communications positive or negative experiences for the client?

      Has your client ever had any psychological testing or counseling?
      Self harming behaviour(s)

      Outside Resources

      Are there any other agencies involved with your client and his/her family?
      Is the client aware of the effects of solvents/substances?
      Is the client's family aware of the effects of solvents/substances?
      Is the client's community worker aware of the effects of solvents/substances?
      Does the family believe the client recognizes that he/she has a problem?
      Has anyone in his/her family or community received treatment for solvent/substance abuse?
      Are the parent(s) supportive of their child receiving treatment? (refer to Referral Agent Agreement and Parental Consent Form)
      Are the extended family members supportive of the family seeking help and/or treatment for themselves or their child?
      Would the family be willing to come to our Treatment Centre to observe the program in action as part of the intake process?

      Medical Assessment

      Are you the client’s regular physician?

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

      Central Nervous System Disorder
      Diagnosed
      Tested
      Chronic bronchitis
      Diagnosed
      Tested
      Asthma
      Diagnosed
      Tested
      Heart problems
      Diagnosed
      Tested
      Gastrointestinal problems
      Diagnosed
      Tested
      Pancreatic problems
      Diagnosed
      Tested
      Kidney or urinary problems
      Diagnosed
      Tested
      Diabetes / hypoglycemia
      Diagnosed
      Tested
      Epilepsy
      Diagnosed
      Tested
      Tuberculosis
      Diagnosed
      Tested
      Chronic pain
      Diagnosed
      Tested
      Eating disorders
      Diagnosed
      Tested
      Sleep disorders
      Diagnosed
      Tested
      Withdrawal symptoms, seizures, etc.
      Diagnosed
      Tested
      Mood disorders (e.g., major depressive disorder)
      Diagnosed
      Tested
      Psychotic disorders (e.g., schizophrenia)
      Diagnosed
      Tested
      Personality disorders
      Diagnosed
      Tested
      Allergies
      Diagnosed
      Tested
      Liver problems: Hepatitis B & C
      Diagnosed
      Tested
      Tuberculosis
      Diagnosed
      Tested
      HIV/AIDS
      Diagnosed
      Tested
      Sexually Transmitted Infections
      Diagnosed
      Tested
      Medical confirmation of pregnancy
      Diagnosed
      Tested
      Is all related testing complete?
      Head Office
      Horse Lake First Nation
      P.O. Box 303 Hythe, AB T0H 2C0
      Sub Office
      Clear Hills Youth Treatment Centre
      P.O. Box 393 Hythe, AB T0H 2C0
      Contact
      587-771-0112info@chytc.ca
      License # MHSPA10000283
      Land Acknowledgement

      We acknowledge we’re on the traditional lands of Treaty 6, Treaty 7, and Treaty 8; home to First Nations, Métis, and Inuit peoples since time immemorial. We honour their deep connections to this land and commit to fostering healing, respect, and reconciliation for future generations.

      © 2024 Clear Hills Youth Treatment Centre | Indigenous Website Design by Saltmedia | 
      facebook-squareCode Snippet ma-customfonts 3.4.2