Get Canada Alberta Health Services 19861 2019-2026

Filling out the Canada Alberta Health Services 19861 form is an essential step for individuals seeking to apply for the Day Treatment Program at the Fort McMurray Recovery Centre. This comprehensive guide will walk you through the process of completing the form online, ensuring that you provide all necessary information accurately.

Follow the steps to effectively complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in your legal name, along with your preferred name if applicable. Make sure to include your date of birth in the format yyyy-Mon-dd.
3. Provide any other names you might have, such as a maiden name or alias, followed by your Personal Health Number (PHN) and age.
4. Select your gender, and then indicate your marital status by choosing one option from the provided list.
5. Enter your mailing address, including city, province, and postal code. Ensure you add your home phone number, alternate or cell phone number, and fax number.
6. State your occupation and the name of your employer. If applicable, indicate any sources that prompted your application by checking the appropriate options.
7. Detail your alcohol and other drug use by describing what substances you use most often, your pattern of use, how long you have been using them, and the date of your last usage.
8. If applicable, repeat step 7 for other substances by specifying types, patterns, duration, and last usage dates.
9. Address any gambling habits by detailing types of gambling, patterns, the duration of your gambling, and when you last gambled.
10. Describe the impact of your substance use and gambling on your life, including effects on relationships, employment, health, and social life.
11. Provide your treatment history, including previously attended treatment programs, and detail your reasons for seeking treatment now.
12. Indicate any special needs or allergies you may have, and list all medications you are currently taking.
13. If under a doctor's care, provide their name and contact information. Address any previous mental health concerns and describe how they have affected your life.
14. If relevant, document any criminal convictions or outstanding legal charges.
15. Read and acknowledge the conditions related to admission by signing and dating the form.
16. Ensure that the referring person completes their section of the form before submission.
17. Return all completed pages by fax or by mail to the designated address. You will have the option to review and save changes, as well as print or share your application.

Complete your application online for the Canada Alberta Health Services 19861 today.