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Residential Family Program
Application

Alcove offers shared accommodations for women who are pregnant or have children under the age of 6.

Alcove’s unique services work towards keeping families intact and allowing mothers and their children

to remain together during the healing process. This is a 12-week treatment program that follows the

same curriculum as the individual program, and in addition provides parent training, cooking classics,

and parent/child relationship rebuilding.

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In order to serve you and get the help you need, please fill out our Application Form below, and it will be

submitted to the Intake Team for assessment. Our Intake Team will contact you for more information.

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If you would like to submit the application form please fill out this PDF and submit it through email at intake@alcoverecovery or fax (403-242-3915).

1 (403) 984 2707

Family Treatment Application Form

Privacy Statement: Alcove abides by the FOIP and CASL laws of Canada regarding the data protection and privacy of all individuals. We do not rent, sell, share or distribute any information submitted in this application. This application is secure.

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Please use this check box to asses your level of need on a scale of 1 to 5Please use this check box to asses your level of need on a scale of 1 to 5Please use this check box to asses your level of need on a scale of 1 to 5Please use this check box to asses your level of need on a scale of 1 to 5Please use this check box to asses your level of need on a scale of 1 to 5Please use this check box to asses your level of need on a scale of 1 to 5Please use this check box to asses your level of need on a scale of 1 to 5
Emergency Contact Info
Health and Medical
Are you Vaccinated Against COVID-19?
If Yes, how many doses?
If you selected no, would you be willing to get vaccinated?
Source of Income
Please select one of the following
Do you have any medical conditions that require special accommodation?
Do you have any mental health conditions?
Addiction History
Type of substance(s):
Marital Status
Are you pregnant?
Do you have children?
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