Canadian Adaptive Climbing - Therapeutic Program Intake Survey
This is an intake survey that is for the purpose of planning our upcoming “Try-It Sessions” for the therapeutic program with the Canadian Adaptive Climbing Society. The information in this survey will be anonymous and kept confidential to protect client information.

The dates for our upcoming Try It Sessions Are:
Sunday, January 15, 2023 from 8:30-10:30am at the Hive Heights, Vancouver
Sunday, January 22, 2023 from 8:30-10:30am at the Hive Heights, Vancouver

Additional information, including an agreement for the release of personal information between program coordinators/volunteers and a consent for care form will be requested upon participation at the Try-It Session, should the client wish to partake in the 6-week therapeutic program.

All confidential and personal medical history will only be accessible to the Occupational Therapist and direct care providers on a need-to-know basis and is stored in accordance with the College of Occupational Therapists of BC (COTBC) Privacy and Security Standards.

Please fill out the intake survey indicating which date you are planning on attending for the Try It Session, prior to the session. Thank you!
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Email *
Which "Try-It Session" are you planning on attending? *
Required
Initials of Participant/Client *
Name of referring practitioner and organization *
Date of referral *
Age *
Nature of Disability *
Required
Fitness Level *
Required
Current or chronic joint injuries likely to be present or affect climber during sessions (ie. tendonitis, sprain, dislocation, bursitis) *
Previous heart health/blood pressure events *
Please check any additional history/medical difficulties that may impact participation in climbing: *
Required
Mobility accessories/assisted devices/facility access needs: *
Do you require a support personnel to assist you with your climbing experience? (this person will need to fill out waivers as well) *
Medical information necessary to ensure we make this a successful climbing experience? *
With your ongoing recovery, do you have any of the following benefits: *
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