Individual Treatment Program Referral Form

Please click here to download the Individual Treatment Program Referral Form.

All pages of the referral forms for the Family Healing Program and Individual Treatment Program must be completed in full and signed (where required). A pre-admission medical form (3 pages) must be completed by a Physician or Nurse Practitioner for each applicant including children.   Once all information is completed, the application can be submitted.  Once submitted, the Treatment Team will screen applications and make a decision whether they are is accepted, declined, deferred or referred to another agency. The screening is completed 2 weeks prior to the start date of the Intake cycle. Please contact the Treatment Program Supervisor and/or Intake Clerk for more information.