HUCCHC Hart Hub
276 Aberdeen Avenue
Hamilton  Ontario  L8P 2R3
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Referral:
HART Hub Hamilton - Residential Treatment ID
Date: 2026-07-12 17:28
Status: Draft
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HART HUB RESIDENTIAL PROGRAM - Application for Residential Treatment

Hamilton Urban Core Community Health Centre (HUCCHC)
HART Hub Hamilton
 
Hide/ShowINSTRUCTIONS

1.  Complete this form electronically or print it and complete it by hand.

2.  Return the completed form by Fax.  Please note that email is not a secure platform, so confidentiality cannot be guaranteed when sending by email.

3.  To book your intake assessment, please call 905-522-3233, ext. 501.

Program
Program location
Mailing address
Phone
Email
Fax
Website
Hide/ShowPERSONAL INFORMATION
First Name
Last Name
Full name at birth (if different)
Chosen Name
Date of Birth
Select Date Clear Date
Gender
Pronouns
Ontario Health Card?
Yes
No
Health Card Number
Home Address
Address Line 1
Address Line 2
City
Postal Code
Province
Permanent address?
Yes
No
Phone Number
Permission to call?
OK to leave a message?
Emergency Contact
Relationship
Emergency Contact Phone
Hide/ShowREFERRAL INFORMATION
Referral Source
How were you referred to the HART Hub Residential Program?
Contact name at referring agency(ies)
Hide/ShowEMPLOYMENT & EDUCATION
Current employment status
Education (highest level achieved)
Hide/ShowINCOME SOURCE
 
Hide/ShowPREVIOUS TREATMENT INFORMATION
Have you had previous substance use treatment?
Yes
No
(if Yes, complete the chart below)
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Treatment Facility / Location
Date Attended
Select Date Clear Date
Program Length
Completed?
Yes
No
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Treatment Facility / Location
Date Attended
Select Date Clear Date
Program Length
Completed?
Yes
No
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Previous treatment at the HART Hub / HUCCHC?
Yes
No
If yes, when
Have you ever had periods when you were not using substances? If so, what coping strategies worked?
(1)
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Hide/ShowIDENTIFIED FAMILY
Which best describes your current relationship status?
Not in a significant relationship
In a significant relationship / partnered
Married
Please identify your immediate family members below:
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Family Member Name
Relationship
Age
Contact with them?
Supportive of treatment?
Problematic substance use?
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Family Member Name
Relationship
Age
Contact with them?
Supportive of treatment?
Problematic substance use?
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If you have children, please complete the chart below:
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Name of Child
Age
Who do they live with?
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Name of Child
Age
Who do they live with?
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Hide/ShowLEGAL STATUS
Do you currently have any outstanding or pending charges, convictions, fines, warrants, court conditions, probation/parole requirements, or other legal restrictions related to any of the following?
Arson or fire-setting
Sexual offence(s)
Violent offence(s) against another person
Weapons offence(s)
Domestic violence-related offence(s)
None of the above
Other (please specify):
 
If you selected any of the above, please provide details, including the current status of the matter:
(e.g., pending, convicted, on probation, court conditions, etc.)
Legal Status:
N/A
On Probation
Incarcerated
Awaiting Trial or Sentencing
On Parole
Other (please specify):
 
Please list all prior convictions
Parole / Probation Officer
Phone
Lawyer
Phone
FPS #
OTIS #
 
Do you have any charges, fines or warrants outstanding or pending?
Yes
No
If yes, please explain
 
Are you currently participating in a Drug Treatment Court program?
Yes
No
Drug Treatment Court Worker
Phone Number
Permission to contact?
Yes
No
Hide/ShowPHYSICAL HEALTH STATUS
Family Doctor (if applicable)
Phone Number
Please check any that apply to you:
Visual impairment
Communicable diseases (e.g. Hepatitis, HIV)
Pregnant
Mobility concerns
Hearing impairment
Acquired Brain Injury
Please describe your current physical health:
Hide/ShowMENTAL HEALTH STATUS
Have you received a mental health diagnosis from a mental health professional?
Within the last 12 months?
Yes
No
Within your lifetime?
Yes
No
If yes, please explain
 
Have you ever attempted suicide?
Yes
No
(if yes, when?):
 
Please describe your current mental health:
MEDICATIONS
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Current medication(s)
Current dosage(s)
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Current medication(s)
Current dosage(s)
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Hide/ShowOPIOID SUBSTITUTION
Are you currently participating in an opioid substitution program?
No
Yes
(if yes, please indicate below)
Methadone
Suboxone
Sublocade
SUBSTANCE USE HISTORY

What substances are you currently using, and how frequently?
 
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Substance
Frequency
1-3 times monthly
3-6 times weekly
Binge
1-2 times weekly
Daily
Method of use
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Substance
Frequency
1-3 times monthly
3-6 times weekly
Binge
1-2 times weekly
Daily
Method of use
Add Section Add  
Hide/ShowPlease indicate any substances used in the past 12 months (select all that apply):
 
Alcohol
Last Date Used
Select Date Clear Date
Method of Use
 
Amphetamines and other stimulants
Last Date Used
Select Date Clear Date
Method of Use
 
Barbiturates
Last Date Used
Select Date Clear Date
Method of Use
 
Benzodiazepines
Last Date Used
Select Date Clear Date
Method of Use
 
Cannabis
Last Date Used
Select Date Clear Date
Method of Use
 
Cocaine
Last Date Used
Select Date Clear Date
Method of Use
 
Crack
Last Date Used
Select Date Clear Date
Method of Use
 
Ecstasy / MDMA
Last Date Used
Select Date Clear Date
Method of Use
 
Glue / Inhalants
Last Date Used
Select Date Clear Date
Method of Use
 
Hallucinogens
Last Date Used
Select Date Clear Date
Method of Use
 
Heroin / Opium
Last Date Used
Select Date Clear Date
Method of Use
 
Methamphetamines (e.g. crystal meth)
Last Date Used
Select Date Clear Date
Method of Use
 
Other psychoactive substances
Last Date Used
Select Date Clear Date
Method of Use
 
Over-the-counter Codeine
Last Date Used
Select Date Clear Date
Method of Use
 
Prescription Opioids
Last Date Used
Select Date Clear Date
Method of Use
 
Steroids
Last Date Used
Select Date Clear Date
Method of Use
 
Tobacco
Last Date Used
Select Date Clear Date
Method of Use
 
Other (please specify)
 
Last Date Used
Select Date Clear Date
Method of Use
Hide/ShowFORM COMPLETION
Date this form was completed
Select Date Clear Date
Thank you for completing this form.
 
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