Pine River Institute
 
 
Admissions Form

Thanks for taking the time to answer these questions. The information you provide here will help us to support your family’s individual needs. When you have completed the form, click the ‘Submit’ button on the bottom right of the page, and someone from our admissions team will be in touch within 24 hours. Please be sure to indicate your phone number or e-mail address, so we can contact you.

Pine River Institute values its relationship with its students (including potential students), their parents, and alumni, and is committed to the protection of their personal information. Accordingly, the Pine River adheres to the privacy principles set out in Schedule 1 of the Personal Information Protection and Electronic Documents Act (Canada).

Inquirer Information
Name:
Relation to Student:
Purpose of Inquiry:
Contact:
(check preferred method of correspondence) OK to leave message/materials?
Home Phone: hrs: Yes No Unknown
Work Phone: hrs: Yes No Unknown
Cell/other Phone: hrs: Yes No Unknown
E-mail: Yes No Unknown
Address: Yes No Unknown

Student Information
Student Name:
Age:
Gender:
Brief description of current situation: (i.e. living at home, in other program, on streets, etc.)
 
Main concerns:
Drugs/alcohol/addictive behaviour Contact with the law
Beyond parental control Eating Disorder
Low self-esteem Self-harm
Rebellious, angry or defiant Violent towards others
Failing in school grades and attendance Bi-Polar
Depressed or emotionally troubled Currently suicidal
Anxiety Impulsive
Abuse/Trauma Running Away
Additional Notes:
Has student had past interventions or treatment?
Briefly describe:
Other/Current supports in place? (i.e. in parent support, family/parent seeing therapist, etc.)
Briefly describe:
Please tell us how you heard about the Pine River Institute.