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  Ontario
Transition House - Intake Form
Date: 2026-06-08 23:19
Hide/ShowCLIENT INFORMATION:
DATE:
Select Date Clear Date
Client Name:
Date of Birth:
Select Date Clear Date
Age Years Months
Ethnicity:
OHIP Number:
Phone Number:
Emergency Contact name and #:
Hide/ShowAGENCY INFORMATION:
Primary Worker:
Agency:
Address:
Phone #:
Fax #:
e-Mail:
Hide/ShowADDITIONAL INFORMATION (to be completed with the client's participation):
Client Day Plan:
(Clients need to be out of the agency between 9 and 4 daily, what recovery activities will he be doing during this time?)
 
Treatment Plan:
(Please be as specific as possible. Include the following: meetings with worker, recovery meetings, aftercare/relapse prevention, healing circles, reconnecting with family, etc)
 
Is Client Ready for Employment?:
 
Education:
(going back to school? Volunteer Work/Exercise? etc.)
 
Housing Goals:
(or other accommodation after Transition House 3 month stay)
 
Health Concerns:
Please describe any significant health concerns and the date/result of last T.B. test.
 
Mental Health Concerns:
(diagnosis, treatment, medications, suicidal ideation/gesture and hospitalization)
 
Legal Involvement:
Including history of violence, outstanding charges, probation/parole and incarceration
 
Substance use history:
(What substances? How would we know if you had gambled or used drugs/alcohol THC use?)
How would we know if you were at risk of using?
 
Transition House is unable to provide TTC tickets. Transition house requires clients to pay fees:
(How will you get to appointments? Will you be able to pay fees?)
 
Can you provide us with any other information that will help us to assist you in completing your goal plan?:
 
Comments:
Email to: info@thousetoronto.org
 
 
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