House of Friendship
236 Victoria St. N.
Unit 3A
Kitchener Ontario N2H 5C8
Referral Type:
LIT - Female-Identifying & Non-Binary
LIT - Male-Identifying & Non-Binary
New Referral
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Referral:
LIT - Male-Identifying & Non-Binary ID
Date:
2025-05-14 00:03
Status:
Draft
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Referring Agency Information
Name of referring agency
Name of referring worker/contact
Worker contact information (phone & extension)
Reason(s) for the referral
Live in Addiction Treatment (if primary concern is not for addiction treatment please do not proceed with referral)
Referral Source - (Please leave as Other)
Self, Family or Friend
Other
Applicant Information
First Name
Last Name
DOB
Gender Identity
Prefer not to answer
I don't identify with any of these options
Woman
Fluid
Man
Non-binary
Trans Man
Trans Woman
Two-Spirit
Unknown to staff
Preferred Pronoun
He/Him/His
He/She/They
He/They
Other
She/Her/Hers
She/They
They/Them/Theirs
Alias/Last Name at Birth
Preferred Name
Program
Preferred Program
Live-In Treatment - Male-Identifying & Non-Binary
Live-In Treatment - Female-Identifying & Non-Binary
Applicant Address
Address Line 1
Address Line 2
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland/Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Out of Country
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Postal Code
Contact Information
Preferred Language
Akan
Algonquin
Amharic
Arabic
Armenian
ASL, (American Sign Language)
Athapaskan languages
Atikamekw
Bengali
Bisayan - Brunei Bisaya
Bisayan - Sabah Bisaya
Blackfoot
Bosnian
Bulgarian
Cambodian - Central Khmer
Cambodian - Northern Khmer
Cantonese
Carrier
Cayuga
Chilcotin
Chinese
Chippewa
Cree
Creoles
Croatian
Czech
Danish
Dari
Delaware
Do not know
Dogrib
Dutch
English
Estonian
Finnish
Flemish
French
Frisian
German
Gitksan
Greek
Gujarati
Hebrew
Hindi
Hungarian
Ilocano
Inuinnaqtun
Inuktitut
Italian
Japanese
Karen
Korean
Kurdish
Kutchin-Gwich'in (Loucheux)
Lao
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Malecite
Maltese
Mandarin
Mennonimee
Mi'kmaq
Mohawk
Montagnais
Naskapi
Nepali
Nisga'a
North Slave (Hare)
Norwegian
Odawa
Ojibwa
Ojicree
Oneida
Other
Other Indigenous Language
Other Native Language
Pashto
Persian (Farsi)
Polish
Portuguese
Pottawatami
Prefer not to answer
Punjabi
Romanian
Russian
Seneca
Serbian
Serbo-Croatian
Shuswap
Sindhi
Sinhala
Siouan Languages (Dakota/Sioux)
Slovak
Slovenian
Somali
South Slave
Spanish
Swahili
Swedish
Tagalog (Pilipino, Filipino)
Taiwanese
Tamil
Telugu
Tigrinya
Tlingit
Turkish
Tuscarora
Ukrainian
Urdu
Vietnamese
Yiddish
Phone (Home/Main)
Permission to call?
Yes
No
Permission to leave a message?
Yes
No
Phone (Alt)
Permission to call?
Yes
No
Permission to leave a message?
Yes
No
Email
Permission to contact via Email
Yes
No
Administrative identification
(Will not impact ability to apply to program)
Health Card
Health Card Version
Health Card Expiration Date
Health Card Issuing Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland/Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Out of Country
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
No Health Card Reason
Lost or Stolen
RCMP
Canadian Forces
Correctional Services
Immigrant
Homeless
Out of Province
Not Available
Refugee - Admission
Other - not eligible
Additional Information
Children in the Home
Yes
No
Number of Children
Legal Issues
Yes
No
Declined
Unknown
Legal Status
Status
Pre-Charge: Court Diversion Program
Pre-Charge: Pre-charge Diversion
Pre-Trial: Awaiting Criminal Responsibility Assessment (NCR)
Pre-Trial: Awaiting fitness assessment
Pre-Trial: Awaiting trial (with or without bail)
Pre-Trial: In community on own recognizance
Pre-Trial: Unfit to stand trial
Custody Status: On parole
Custody Status: On probation
Custody Status: ORB conditional discharge
Custody Status: ORB detained - community access
Outcomes: Awaiting sentence
Outcomes: Charges withdrawn
Outcomes: Conditional discharge
Outcomes: Conditional sentence
Outcomes: Incarcerated
Outcomes: NCR
Outcomes: Peace bond
Outcomes: Restraining order
Outcomes: Stay of proceedings
Outcomes: Suspended sentence
*MCYS - Detention community release plan
*MCYS - Found Guilty/Sentenced
*MCYS - New Charges
*MCYS - No new charges
Mentally Disordered
Mandatory Supervision
Forensic Psychiatric
Other: No legal problem (includes absolute discharge and time served-end of ...
Prefer not to answer
Do not know
Other Criminal Problems
Legal Issue details
Culture and Language
Indigenous Status
Indigenous
Non-indigenous
Prefer not to answer
First Nations people
Metis
Do not know
Inuit
Mother Tongue/First Language
Akan
Algonquin
Amharic
Arabic
Armenian
ASL, (American Sign Language)
Athapaskan languages
Atikamekw
Bengali
Bisayan - Brunei Bisaya
Bisayan - Sabah Bisaya
Blackfoot
Bosnian
Bulgarian
Cambodian - Central Khmer
Cambodian - Northern Khmer
Cantonese
Carrier
Cayuga
Chilcotin
Chinese
Chippewa
Cree
Creoles
Croatian
Czech
Danish
Dari
Delaware
Do not know
Dogrib
Dutch
English
Estonian
Finnish
Flemish
French
Frisian
German
Gitksan
Greek
Gujarati
Hebrew
Hindi
Hungarian
Ilocano
Inuinnaqtun
Inuktitut
Italian
Japanese
Karen
Korean
Kurdish
Kutchin-Gwich'in (Loucheux)
Lao
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Malecite
Maltese
Mandarin
Mennonimee
Mi'kmaq
Mohawk
Montagnais
Naskapi
Nepali
Nisga'a
North Slave (Hare)
Norwegian
Odawa
Ojibwa
Ojicree
Oneida
Other
Other Indigenous Language
Other Native Language
Pashto
Persian (Farsi)
Polish
Portuguese
Pottawatami
Prefer not to answer
Punjabi
Romanian
Russian
Seneca
Serbian
Serbo-Croatian
Shuswap
Sindhi
Sinhala
Siouan Languages (Dakota/Sioux)
Slovak
Slovenian
Somali
South Slave
Spanish
Swahili
Swedish
Tagalog (Pilipino, Filipino)
Taiwanese
Tamil
Telugu
Tigrinya
Tlingit
Turkish
Tuscarora
Ukrainian
Urdu
Vietnamese
Yiddish
Substance Use
Primary Problem Substance:
Alcohol
Amphet. & other stimulants exc. Methamphetamines
Barbiturates
Benzodiazepines
Cannabis
Cocaine
Crack
Ecstasy
Fentanyl
Glue & other inhalants
Hallucinogens
Heroin/Opium
Methamphetamines (crystal meth.)
None
Other psychoactive drugs
Over-the-counter codeine preparations
Prescription Opioids (excl. Fentanyl)
Steroids
Tobacco
Unknown
Frequency in Last 30 Days:
Did not use
1-3 times monthly
1-2 times weekly
3-6 times weekly
Daily
Binge
Unknown
Substance Use Goal
Abstinence
Reduce Use
Harm Reduction
Presenting Problem Substance:
Alcohol
Amphet. & other stimulants exc. Methamphetamines
Barbiturates
Benzodiazepines
Cannabis
Cocaine
Crack
Ecstasy
Fentanyl
Glue & other inhalants
Hallucinogens
Heroin/Opium
Methamphetamines (crystal meth.)
None
Other psychoactive drugs
Over-the-counter codeine preparations
Prescription Opioids (excl. Fentanyl)
Steroids
Tobacco
Unknown
Frequency in Last 30 Days:
Did not use
1-3 times monthly
1-2 times weekly
3-6 times weekly
Daily
Binge
Unknown
Substance Use Goal
Abstinence
Reduce Use
Harm Reduction
Presenting Problem Substance:
Alcohol
Amphet. & other stimulants exc. Methamphetamines
Barbiturates
Benzodiazepines
Cannabis
Cocaine
Crack
Ecstasy
Fentanyl
Glue & other inhalants
Hallucinogens
Heroin/Opium
Methamphetamines (crystal meth.)
None
Other psychoactive drugs
Over-the-counter codeine preparations
Prescription Opioids (excl. Fentanyl)
Steroids
Tobacco
Unknown
Frequency in Last 30 Days:
Did not use
1-3 times monthly
1-2 times weekly
3-6 times weekly
Daily
Binge
Unknown
Substance Use Goal
Abstinence
Reduce Use
Harm Reduction
Presenting Problem Substance:
Alcohol
Amphet. & other stimulants exc. Methamphetamines
Barbiturates
Benzodiazepines
Cannabis
Cocaine
Crack
Ecstasy
Fentanyl
Glue & other inhalants
Hallucinogens
Heroin/Opium
Methamphetamines (crystal meth.)
None
Other psychoactive drugs
Over-the-counter codeine preparations
Prescription Opioids (excl. Fentanyl)
Steroids
Tobacco
Unknown
Frequency in Last 30 Days:
Did not use
1-3 times monthly
1-2 times weekly
3-6 times weekly
Daily
Binge
Unknown
Substance Use Goal
Abstinence
Reduce Use
Harm Reduction
Presenting Problem Substance:
Alcohol
Amphet. & other stimulants exc. Methamphetamines
Barbiturates
Benzodiazepines
Cannabis
Cocaine
Crack
Ecstasy
Fentanyl
Glue & other inhalants
Hallucinogens
Heroin/Opium
Methamphetamines (crystal meth.)
None
Other psychoactive drugs
Over-the-counter codeine preparations
Prescription Opioids (excl. Fentanyl)
Steroids
Tobacco
Unknown
Frequency in Last 30 Days:
Did not use
1-3 times monthly
1-2 times weekly
3-6 times weekly
Daily
Binge
Unknown
Substance Use Goal
Abstinence
Reduce Use
Harm Reduction
Presenting Problem Substance:
Alcohol
Amphet. & other stimulants exc. Methamphetamines
Barbiturates
Benzodiazepines
Cannabis
Cocaine
Crack
Ecstasy
Fentanyl
Glue & other inhalants
Hallucinogens
Heroin/Opium
Methamphetamines (crystal meth.)
None
Other psychoactive drugs
Over-the-counter codeine preparations
Prescription Opioids (excl. Fentanyl)
Steroids
Tobacco
Unknown
Frequency in Last 30 Days:
Did not use
1-3 times monthly
1-2 times weekly
3-6 times weekly
Daily
Binge
Unknown
Substance Use Goal:
Abstinence
Reduce Use
Harm Reduction
Have you had periods of abstinence in the past? When and for how long?
What strategies have helped in the past?
Have you participated in any substance use treatment in the past? Please provide details.
Any other behavioural addictions you are concerned about (gambling, gaming, use of technology or other?)
Health Status/Problems
Vision:
Yes
No
Unknown
Hearing
Yes
No
Unknown
Mobility
Yes
No
Unknown
Pregnancy
No
Not Applicable
Possibly
Yes
Declined
Unknown
Non-Medical Intravenous Drug Use:
Never Injected
Injected prior to one year ago
Injected in the last 12 months
Unknown
Number of overnight hospitalizations in the last 12 months for physical problems
(a value of '999' means unknown)
Reason for most recent hospitalization:
Accident
Accidental Overdose
Addiction
Allergic Reaction
Attempted Suicide
Birth of Baby
Cancer
Cardiac
Complications of Injection Drug Use
Detoxification
Diabetes
Eating Disorder
Gastrointestinal
HIV/AIDS
Head Injury
Hepatitis
Infection
Kidney Disease
Liver Disease (except Hepatitis)
Mental Health
Respiratory
STD
Seizures
Surgery
Tuberculosis
Not Applicable
Diagnosed with a mental health problem by a qualified professional:
Within the last 12 months:
Yes
No
Unknown
Within lifetime:
Yes
No
Unknown
Most recent diagnosis #1:
ADD/ADHD/Disruptive Behaviour Disorder
Adjustment Disorder/Situational Crisis
Antisocial Personality Disorder
Anxiety Disorder
Bipolar Affective Disorder
Borderline Personality Disorder
Delirium
Dementia
Eating Disorder
Major Depressive Disorder
Narcissistic Personality Disorder
Obsessive Compulsive Disorder
Pain Disorder
Panic Disorder with Agoraphobia
Panic Disorder without Agoraphobia
Paranoid Personality Disorder
Paranoid Personality Disorder
Post Traumatic Stress Disorder
Psychotic Disorder
Schizoaffective Disorder
Schizophrenia
Substance Abuse
Substance Dependence
Substance Induced Mood Disorder
Substance Induced Psychotic Disorder
Substance Intoxication
Substance Withdrawal
Not Applicable
Most recent diagnosis #2:
ADD/ADHD/Disruptive Behaviour Disorder
Adjustment Disorder/Situational Crisis
Antisocial Personality Disorder
Anxiety Disorder
Bipolar Affective Disorder
Borderline Personality Disorder
Delirium
Dementia
Eating Disorder
Major Depressive Disorder
Narcissistic Personality Disorder
Obsessive Compulsive Disorder
Pain Disorder
Panic Disorder with Agoraphobia
Panic Disorder without Agoraphobia
Paranoid Personality Disorder
Post Traumatic Stress Disorder
Psychotic Disorder
Schizoaffective Disorder
Schizophrenia
Substance Abuse
Substance Dependence
Substance Induced Mood Disorder
Substance Induced Psychotic Disorder
Substance Intoxication
Substance Withdrawal
Not Applicable
Hospitalized for a mental health problem:
Within last 12 months:
Yes
No
Unknown
Within lifetime:
Yes
No
Unknown
Received treatment for a mental health, emotional, behavioural or psychological problem from a community mental health program or professional:
Currently:
Yes
No
Unknown
Within last 12 months:
Yes
No
Unknown
Within lifetime:
Yes
No
Unknown
Name of Service provider and job title:
(if currently receiving treatment)
Contact info for service provider:
(if currently receiving treatment)
Prescribed medication for a mental health problem:
Currently:
Yes
No
Unknown
Within last 12 months:
Yes
No
Unknown
Within lifetime:
Yes
No
Unknown
Prescribed Drugs
Prescribed Opioid Use Disorder Medications
Methadone/Suboxone/Sublocade/other anti-craving medication
Yes
No
Prescriber
Phone
Prescription Details
?