Intake Form - Wakenagun

You can complete the application on your own device by downloading the form below. Submit the completed PDF via email to: intake@kanachihih.ca.

Provide as much information as possible, and if there are any questions that are Not Applicable (N/A) or Unknown (UNK), please indicate so.

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Centralized Referral Form

Please check off which healing lodge you are applying for:

KA-NA-CHI-HIH (18-29 YEARS OLD)

WAKENAGUN (12-17 YEARS OLD)

PELICAN HIGH PEAK (12-17 YEARS OLD)

First Name

Last Name

Middle Name

Age

Date of Birth

Gender

Sex

Preferred Pronoun

Address

Province/Territory

Postal Code

Marital Status

Phone #

Health Card #

Version Code

Expiry Date

Band Name

Status Card #

Status Indian

Inuit

Métis

Non-Status

Language(s) Spoken

Language(s) Understood

Reason for Referral

If you are human, leave this field blank.