Funding Application For Out Of Province Mental Health And Or Addictions Page 2

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3. Why is the patient unable to maintain sobriety and continuing to use substances despite active outpatient treatment in the
last three months?
4. Is partial hospitalization or intensive outpatient treatment medically appropriate now?
Yes
No
If no, please explain:
5. How would the patient’s current social and living environment sabotage attempts at outpatient treatment?
6. Has the patient been hospitalized in the past 10 years for addiction and mental health?
Yes
No
If yes, please provide details:
Program Name
Diagnosis
Admission and
Outcome
Discharge Date
A
D
A
D
A
D
If no, please explain:
HLTH 2809 2010/08/12
PAGE 2 OF 4

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