Pine River Institute – A Therapeutic Boarding School, For Teens Who Are in Crisis

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 School 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 Stabilized on medication?
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.

Pine River Institute is a non-profit organization. Charitable #874627516RR0001