First Name
Middle Initial
Last Name
Street Address
Address (cont.)
City
Province
Postal Code
Home Phone
Work Phone
Email Address
Date of Birth (mm/dd/yy)
Health Card Number
Gender	MaleFemale
Name of close relative or friend for contact purposes.
First Name
Middle Initial
Last Name
Street Address
Address (cont.)
City
Province
Postal Code
Home Phone
Work Phone
Email Address
Please list the time periods you spent in Oak Ridge	a) b) c) d)
Psychiatric Diagnosis:
Were you in the Motivation Attitude Participation Program (M.A.P.)?	Yes   No
If yes, please list the dates of participation.	a) b) c) d)
Were you placed in the Total Encounter Capsule Program?	Yes    No
If yes, please list the dates of participation.	a) b) c) d)
Please describe what drugs you were given while in the Capsule.
Were you in the Defence Disruptive Therapy Program (D.D.T.)?	Yes    No
If yes, please list the dates of participation.	a) b) c) d)
Please describe what drugs you were given as part of the D.D.T program..