Residential Adult Addiction Treatment
Page 1 of 9
Office Use Only
Client ASIST #
A room and board fee of $40.00 per day for Alberta residents, $125.00 per day for out-of-province residents and
$200.00 per day for clients attending the Business and Industry Clinic will apply.
Please complete pages one to five of this form and have the referring person
(if applicable) complete page six. The
medical assessment on pages seven to nine must be completed by a medical doctor or nurse practitioner.
Return all pages by fax or by mail to the appropriate centre below. Unanswered questions, incomplete or illegible
answers may delay your admission.
Please check the centre you are applying for. You may only select one.
o Business and Industry Clinic o Northern Addictions Centre
11333 - 106 Street 11333 - 106 Street
Grande Prairie, AB T8V 6T7 Grande Prairie, AB T8V 6T7
Phone: 780.538.6316 Fax: 780.538.6313 Phone: 780.538.6350 Fax: 780.538.6313
o Lander Treatment Centre o Henwood Treatment Centre
P.O. Box 1330 18750 18 Street NW
221 - 42 Avenue West Edmonton, AB T5Y 6C1
Claresholm, AB T0L 0T0 Admissions: 780.422.4466
Admissions: 403.625.5600 Switchboard: 780.422.9069 Fax: 780.422.5408
Switchboard: 403.625.1395 Fax: 403.625.1300
o Fort McMurray Recovery Centre o Medicine Hat Recovery Centre
451 Sakitawaw Trail 370 Kipling Street SE
Fort McMurray, AB T9H 4P3 Medicine Hat AB, T1A 1Y6
Phone: 780.793.8300 Fax: 780-793-8301 Phone: 403.529.9021 Fax: 403.529.9065
Legal name (last, first, middle)
What name do you like to be called? Other name (e.g. maiden name or an alias)
Marital status (Choose one only)
o Single/Never married o Married/Common-Law/Partnered o Widowed
o Separated o Divorced
Three months ago, were you a resident of a province or territory other than Alberta?
o Yes, what date did you take up residency in Alberta?
(proof of Residency may be required)
What is your occupation? Who is your employer?
If your application was prompted, please check all that apply
o Addiction Services Office o Physician
o Child Welfare Worker o Psychiatrist/Psychologist/Mental Health Worker
o Addiction Funded Agency o Employer/Employee Assistance Program
o Social Services/Income Support Worker o Court/Parole Office/Probation Officer/Lawyer
Home Phone Alternate or Cell Phone Fax Number
City Province Postal Code
Date of Birth (yyyy-Mon-dd) Personal Health Number (PHN) Age