Appointment Request

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The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

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Required format:

Welcome to the Youth - VAST (Vaping, Alcohol, Substance use, and Technology) Dependence Program! We're so glad that you're here.

To get started, please complete this Appointment Request Form, and a member of our team will reach out within 1-2 business days to confirm your appointment. We'll use the information you provide to create a confidential health record.

If you're a parent, guardian, or someone filling out this form for a young person, please make sure that they know the appointment is being requested on their behalf.

For more information, please contact 1-833-413-6556 or youth.VAST@camh.ca.

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Appointment request date:

NB: equivalent to referral date.

D-M-Y H:M

Are you requesting an appointment for yourself?

* must provide value

Yes

No, I am requesting on behalf of someone else

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What is your relationship to the person for whom you are requesting an appointment?

* must provide value

Parent/Guardian

Education Provider

Primary Care Provider

Other, please specify:

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How did you hear about us?

School

Education Provider

Friend

Social Media

CAMH Website

Other, please specify: arf_hear_other

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Youth Information

Legal first name: * must provide value	Legal last name: * must provide value

Preferred name:	Pronouns:

Preferred email address: * must provide value	Preferred contact number: * must provide value

Current mailing address: * must provide value	City: * must provide value

Province: * must provide value	Postal Code: * must provide value
	Please enter a valid postal code in the format A1A1A1.

Are you between the ages of 12 and 21?

Youth-VAST is for youth ages 12-21. If you're outside this age range, the survey will end. For support at CAMH, call Access CAMH at 416-535-8501, and select option 2.

Yes

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What's your date of birth?

* must provide value

D-M-Y

You have selected an age that does not meet the Youth-VAST eligibility criteria. Youth-VAST is for youth ages 12-21 only. Even if you complete the rest of the form, we unfortunately will not be able to proceed. For support at CAMH, please call Access CAMH at 416-535-8501 and select option 2.

Please note: When you register for a CAMH outpatient program, we ask you for your health insurance coverage information. If you do not have OHIP/a health card, we will need information about any private health insurance you may have, or will work with you to access other coverage as needed.

Health Coverage Information

When you register for a program at CAMH, we ask you for your health insurance information.

If you do not have an Ontario health card (OHIP), that's okay! When we confirm your appointment, we will either ask about any private coverage you have or help you access other options.

Do you have an Ontario health card (OHIP)?

Yes

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Do you have your health card with you?

Yes

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Health card number:	Health card version code:
e.g.,1234 567 890	e.g., AB

I do not have an Ontario health card

Health card expiry date:

* must provide value

Y-M-D

Do you have a family doctor?

Yes

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What is the name of your family doctor?

Emergency Contact Information

First name: * must provide value	Last name: * must provide value

Relationship to youth: * must provide value	Phone number: * must provide value

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.