Casting Call - Intervention Canada

Is your loved one struggling with an addiction or compulsive behavior?

If you would like to have your loved one considered for participation on Intervention Canada, please complete the form below. The information you provide will be submitted directly to the production team at Intervention Canada for Shaw Television Inc. ("Shaw"). Your information will not be seen by Shaw unless presented to Shaw by the production team. By submitting this information, you give the right to use the information below in connection with Intervention Canada, for the purposes of making casting and other decisions with respect to the production and public viewing of Intervention Canada. Note that this information may be incorporated into the Program, at producer's sole discretion.

You acknowledge that you may not receive a response from this submission.

IF YOU BELIEVE THAT THE SITUATION YOU DESCRIBE BELOW REQUIRES URGENT ATTENTION, PLEASE CONTACT AN APPROPRIATE CARE PROVIDER. Click here for Provincial Help Lines and Resources.

If you are chosen to participate you will be required to sign appropriate releases. If you or the participant is under the age of majority (18 years in Alberta, Manitoba, Ontario, Prince Edward Island, Quebec and Saskatchewan and 19 years elsewhere in Canada) in your province of residence the participant must have parental or legal guardian consent before participating.

(Please remember that the person suffering from an addiction cannot know about the possible intervention or offer of treatment in order to ensure the best chances for success.) PLEASE DO NOT INCLUDE THE ADDICT'S CONTACT NUMBERS OR EMAIL ADDRESS IN FIELDS BELOW.

Intervention Canada Participation Form

* First Name:
* Age:
* Your Occupation:
* Your Email Address:
* Your Primary Phone Number:
Your Primary Phone Number Type:
* Does addict have use of the phone or voicemail at this number:
* Alternate Phone Number:
Alternate Phone Number belongs to:
Alternate Phone Number Type:
* City/Town:
* Province:
* Country:
* Addict's Name:
* Addict's Age:
Addict's Occupation (if applicable – optional):
Addict's Ethnicity (optional):
Addict's City:
Addict's State / Province:
Addict's Country:
* How long has he/she been addicted? (years,months):
* Type of addiction/compulsive behavior:
* Frequency of use (or compulsive behavior) per day:
* How many friends and family would participate in an intervention?:
* Please describe your loved one's accomplishments and personality BEFORE the addiction, and describe your loved one's personality and situation NOW:	A value is required. Exceeded maximum number of characters.
* What do you believe caused your loved one's addiction:	A value is required. Exceeded maximum number of characters.
* Why isn't your loved one getting help on his/her own to overcome their addiction? Has your loved one gotten help before? If so, what kind, when, and how long did the treatment last?:	A value is required. Exceeded maximum number of characters.
* Please list your loved one's weekly activities and the people he/she spends most time with:	A value is required. Exceeded maximum number of characters.
A value is required.* I, Agree to complete and submit this story submission form (the "Form") for the purpose of being considered to become a participant in the television show entitled "Intervention Canada" (the "Program"). I am making the representations, disclosures, and agreements described below in this Form so that Producer will continue to consider me to become a participant in the Series. If any disclosure or representation is false, misleading or incomplete, or if I breach any agreement made in connection with the Series, Producer may remove me from further consideration as a participant. I agree that I have not made, nor will I ever make any false or misleading statements regarding the Program, my participation Program, or the person that I am submitting for appearance in the Program ("Subject"). I agree that I have not, nor will I engage any deceptive or dishonest act with respect to the Program, including but not limited to informing the Subject about the intervention or offer of treatment, the intended outcome of the Program, or any confidential knowledge I have with respect to the Program.
* PLEASE CHECK THIS BOX WHICH SIGNIFIES THAT YOU ARE AGREEING TO THE ABOVE TERMS OF THE STORY SUBMISSION FORM
* Confirmation Phone (same as phone above):
* Date:
* Person that is the subject of the story: