BANA Clinical Intake Form

BANA ASSESSEMENT/INTAKE FORM

Today's Date (dd/mm/yyyy) (click on box for drop down calendar)

First Name

Last Name

I consent to be contact via the email address provided

Yes

Phone # (with area code)

Phone Permissions

Permission to contact via phone

Permission to leave a message

date of birth (yyyy/mm/dd)

Age

Address

Street Address

Address Line 2

City

Province

Postal Code

Do you have a primary care provider (required to access treatment)?

Yes

Gender Identity:

Pronouns (ie: she/her):

Indigenous Status

Primary Language Spoken

Assessment services are provided in English. Do you require a translator?

Yes

Language of translation needed

Reason for contacting BANA:

How did you hear about our services?

I acknowledge and understand that due to high volume of applicant requests there is an extended wait period for our program and services at this time. BANA Clinical Treatment services are for those 20 and older living in Windsor-Essex area, Teen Health Centre Clinical services are for those ages 12-25.

THE ASSESSMENT APPOINTMENT THIS IS NOT A COUNSELING APPOINTMENT; IT IS STRICTLY TO ASSESS PROGRAM ELIGIBILITY

I have read and agree to these Terms and Conditions.