Application for Assessment

COVID 19 Protocols

If you have completed residential addiction treatment within the last year, please complete this form either online, or download the application and fax or email the form. Also please look at our Admissions and Expectations page.

Applicants can call us to follow up 2 days after submitting this form if they haven’t received a response (780) 426-1409.

Fill out the form below.

Or click here to jump down the page to download the application

Consent to Assessment*
Click here to read the Consent to Assessment. Please read before completing the Assessment Application >
By selecting "yes" below, I confirm that I have reviewed and understood the Consent to Assessment, specifically (1) the McDougall House Assessment Philosophy, (2) the Assessment process and (3) the benefits and material risks of assessment as outlined above and would like to proceed with an assessment.
- Yes
- No
Have you or will you complete residential addiction treatment?*
What is the name of the treatment centre?*
On what date did you or will you complete treatment?*
MM slash DD slash YYYY
Completion of a residential addiction treatment program is required.
Hidden
Full Name:*
First Middle Last
Age:*
Phone Number:*
Email:*
Province:*
Healthcare Number:*
Addiction Information
For what addictions are you seeking help?*
What date was your last use of alcohol or drugs?*
MM slash DD slash YYYY
Are you an I.V. drug user?*
- Yes
- No
What mood altering substances (including alcohol, drugs, medications) have you used in the past year?*
When were you last in Detox?*
Are you at a treatment centre?*
- Yes
- No
If yes:*
What is the name of the facility? Where is it located? When do you graduate?
Who is your Addiction Counsellor in Treatment?
First Last
Your addiction counsellor's phone number:
Your addiction counsellor's email address:
Health Information
Have you ever been hospitalized due to your use? If yes, when and where?
Do you have a Mental Health diagnosis? If yes, please specify.
Are you on any medications, including Suboxone or Methadone? If so, which ones and dosage? Please include date started (Please fax a copy of current medications from Treatment/ Pharmacy)*
Medication Start Date Dosage
Do you have any open wounds, skin infections or have you had any recent surgeries? If yes, please specify:*
Do you have a new or worsening cough, a cold or the flu? If Yes: shortness of breath? rash or diarrhea? or fever in last 24 hours?
Any recent exposure to Chicken Pox, Measles, Mumps, Whooping cough, Tuberculosis? If yes, please specify.*
Where have you lived over the past year (own home, rented, shelters, jail, couch surfing, treatment, etc.)?*
Have you ever been Physically, Emotionally or Sexually abused?*
- Yes
- No
Have you had counselling for this Abuse? If yes, when?
More Information
Do you have any legal issues or court dates? If yes, please specify:*
Do you have children? If yes, please list age and first name:*
First Name Age
Is Child and Family Services involved? If yes, please specify arrangement with children:
How would you fund your stay at McDougall House?*
If Social Services, which office or workers name?*
Who referred you to McDougall House or how did you hear about us?*
NOTE:
To submit this application, you need to confirm that you have reviewed and understood the (1) McDougall House Assessment Philosophy, (2) the Assessment process and (3) the benefits and material risks of assessment as outlined above and would like to proceed with an assessment. See top of this page.

Or Download the Application

Download the Application for Assessment

PDF Version

Two Options to Submit the Application:

1. Fax: 780-429-3459
2. Email: [email protected]

Applicants can call us to follow up 2 days after submitting this form if they haven’t received a response (780) 426-1409.

What is the name of the facility?	Where is it located?	When do you graduate?

Medication	Start Date	Dosage

First Name	Age

Application for Assessment

Fill out the form below.

NOTE:

Or Download the Application

Download the Application for Assessment

Two Options to Submit the Application: