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Toll-Free: General Inquiries: 1-844-633-0135

New Beginnings Referral Form

Please fill out the form below and someone from our team will be in touch soon.

Referral & Applicant Details

Applicant Name

First Name

Last Name

Date of Birth:

Year

Month

Day

Phone Number *

Email Address *

Identity (Optional)

Metis

First Nations-Status

Non-Status

Earliest entry date:

Year

Month

Day

Referral agent: *

Service/Agency *

Phone Number *

Email Address *

Immediate Safety & Eligibility

Medical detox currently required? *

Yes

No

Currently subject to violence? *

Yes

No

Alberta resident? *

Yes

No

Medically stable?

Yes

No

Mental health currently stable? *

Yes

No

Pregnant? *

Yes

No

Important: New Beginnings cannot accept applicants requiring medical detox. Arrange detox services before intake.

Substance Use & Treatement

Seeking sobriety/substance-use support? *

Yes

No

Overdose in past 90 days? *

Yes

No

Seeking pre-treatment support? *

Yes

No

Currently completing treatment / seeking post-treatment support? *

Yes

No

Prior recovery community/TLU? *

Yes

No

Prior treatment experience? *

Yes

No

Primary substance: *

Secondary substance: *

Previous Treatment

Dates and locations

Medical Information

Current medical/mental health diagnoses or disabilities? *

Yes

No

Details

Medications

List medication, dose, frequency

Attach MAR if available

Opiate agonist/replacement therapy? *

Yes

No

Which?

Community Living & Legal

Suitable for shared/community living? *

Yes

No

Criminal record? *

Yes

No

Arson-, child-, or sexually related charges/convictions? *

Yes

No

Court-mandated treatment? *

Yes

No

Primary motivation/goal: *

Consent and Agreement

Consent and Agreement *

I consent to New Beginnings obtaining relevant medical and social history, using it to assess program eligibility and support needs, and storing it in my program file. I confirm the information provided is accurate to the best of my knowledge.

Applicant Name *

Applicant Signature *

Date

Date

Staff notes (optional)

Acuity score:

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