VQ Online Application FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastGenderFemaleMaleNon-BinaryTransgender MaleTransgender FemalePrefer not to sayEmail *Phone NumberStreet AddressCityProvincePostal CodeEmergency Contact FirstLastEmergency Contact RelationshipEmergency Contact Phone NumberEmergency Contact Email AddressAre you on Government Assistance? (welfare, disability, PWD, EI, etc.)What substances are you struggling with?AlcoholMethamphetamineKetamineAmphetaminesSynthetic DrugsStimulants (Uppers)Cocaine/CrackFentanylInhalantsNicotineLSDDepressants (Downers)GHBMDMA/MollyCannabisPsilocybin mushroomOpioids (heroin, morphine, codeine, prescription painkillers, fentanyl)OtherHave you been diagnosed with... (select all that apply)ADHDAnxietyAutoimmune DiseaseBi-PolarDepressionDiabetesEpilepsyHepatitisHIVPTSDSchizophreniaDO you struggle with any self-harm or suicidal thoughts?YesNoHave you had any hospitalizations in the last 30 days? If so, please elaborate:Have you had a tuberculosis (TB) test in the last 3 years?YesNoList all current medications:List all allergies:Have you ever been charged or convicted of any sexually related offences, arson, or any crimes against minors?YesNoDo you currently have any criminal charges? If yes, who is your lawyer, and are you on bail or probation? (This does not determine your eligibility)Is there anything else you would like us to know? Gender works 3 What day(s) work best to contact you?MondayTuesdayWednesdayThursdayFridayWhat time of day works best for you?MorningAfternoonSubmit
