Request an Appointment with the Interior Health Virtual Addiction Medicine (VAM) Clinic I am seeking help: For myself For a friend or family member For my client (non-clinical service provider, e.g. housing or outreach) Your First Name: Your Last Name: Your relationship to the person you are seeking help for: Is the person aware you are seeking help for them: Yes No Your Phone Number? If you are a clinical service provider please complete the clinical referral form Your First Name: Your Last Name: Your Clinic or Organization: Is the client aware of this referral: Yes No Your Phone Number? I am seeking help for: Opioid use (e.g. fentanyl, “down”, heroin, or morphine) Alcohol use Other Stopping alcohol suddenly without medical support can be dangerous. The Virtual Addiction Medicine Clinic only provides support for opioid use and alcohol use at this time. Please contact your closest Mental Health and Substance Use clinic at 310-MHSU (6478). If you need immediate help, visit your nearest emergency department, or call a 24-hour crisis line. Interior Crisis Line Network: 1-888-353-2273 or 1-800-784-2433 KUU-US (Indigenous) Crisis Line: 1-800-588-8717 Métis Crisis Line: 1-833-638-4722 Contact information for the person needing help Contact information for the person needing help First Name Last Name Preferred Name Date of Birth? BC personal Health Number? I’m not sure or I don’t have a BC Personal Health Number Phone Number? Email Address? What is the best way to contact you? This may include a phone number for a friend or family member, or a shelter or other place you often go. Is there a best time to contact you? Address I do not have an address Street Address City - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewan Province Postal Code? CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.