Appointment Request

The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

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 U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

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

Youth-VAST is a program for youth in Ontario between the ages of 12 and 21 who are using substances or vaping, or feel like technology is taking up too much of their time. Many people have these struggles, and we are here to help you figure out the best ways to take care of yourself. This program brings together existing and new resources across CAMH to deliver virtual services directly to you and your family.

Please complete the following Appointment Request Form to book a virtual appointment with a Youth-VAST Care Coordinator. A member of our team will contact you within 1-2 business days to confirm your appointment. Your information will be collected and used to create a CAMH patient health record.

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

reset

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:

reset

I am seeking help with... (Check all that apply.)

* must provide value

Vaping

Substance Use (e.g., alcohol use, cannabis use, caffeine or other energy drinks)

Technology Use (e.g., Internet, computer, gaming, social media, smart phone)

Do you require an interpreter?

Yes

reset

Please specify the type of sign or spoken language for which you require an interpreter:

How did you hear about us?

School

Education Provider

Friend

Social Media

CAMH Website

Other, please specify:

reset

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

Preferred name:		Date of birth: * must provide value

Email address: * must provide value		Primary contact number: * must provide value

Home address: * must provide value		Province: * must provide value

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

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.

I do not have an Ontario health card

Health card number:

* must provide value

Health card version code:

* must provide value

Health card expiry date:

* must provide value

Y-M-D

Do you have a family doctor?

Yes No

reset

What is the name of your family doctor?

Emergency contact first name:

* must provide value

Emergency contact last name:

* must provide value

Emergency contact number:

* must provide value

Emergency contact relationship to youth:

* must provide value

Please select your preferred appointment days and times (appointments are generally 60 minutes):

Monday		Thursday

Tuesday		Friday

Wednesday

I consent to receive the following communications from the Youth-VAST Program: details about my appointment, information about the program, and links to questionnaires to complete to inform clinical decisions about my care.*

* must provide value

* Providing this information means that you consent to be contacted, and to receive calls, emails, and/or text messages from CAMH. You acknowledge and understand email and text messages are not encrypted on the hospital system; therefore, CAMH cannot guarantee the security and confidentiality of messages you send to or receive from CAMH.

You understand that email and/or text does not replace established clinical processes such as face-to-face assessment, consultation or intervention. You understand that your care provider may make decisions about your treatment based on information you provide through email and/or text and that this information will also form part of your health record if it is relevant to your care. You also understand that your email and/or text and/or the information in it may be seen or used by people other than the intended recipient, for a variety of purposes - for example, to update your health records or to permit others to assist in your care.

If you would like to update your preference for communications, or your email address or phone number changes, please let us know by emailing youth.VAST@camh.ca.

Please note, given CAMH is an academic research hospital you may be invited to participate in research opportunities at CAMH. Participation in research is completely voluntary and will not affect your access to clinical care. As well, given CAMH is a teaching hospital, you can expect to have residents or students involved in your care.

What are your preferred method(s) of communication? (Check all that apply.)

Please note that we will do our best to accommodate your preferred method of communication; however, details about my appointment, information about the program, and links to questionnaires may be sent via email.

* must provide value

Call me

Send me an email

Send me a text

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.