Intake Form | Ka-Na-Chi-Hih

Please check off which healing lodge you are applying for:

KA-NA-CHI-HIH (18-29 YEARS OLD)

WAKENAGUN (12-17 YEARS OLD)

PELICAN HIGH PEAK (Family)

Reason for Referral

First Name

Last Name

Date of Birth

Age

Gender

Pronouns

Sex

Street Address

City

Province/Territory

Postal Code

Marital Status

Phone #

Email

Health Card #

Version Code

Expiry Date

Status Card #

Expiry Date

Nation Status

First Nation Community

Language(s) Spoken

Language(s) Understood

First Name

Last Name

Agency

Relationship

Phone Number

Is this a self referral? (yes/no)

Do we have consent to speak to your referral source to facilitate the intake process? (yes/no)

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