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Individual Residential Program
Application

This is a highly structured, intensive, residential treatment program provided in a safe, home-like setting in the community.  It is a 12-week program of discovery and empowerment for women, with a holistic approach, and both trauma-informed and gender-specific.

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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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Please note that all applications must be submitted online using the designated form. We do not accept applications through any other method. Please ensure all required fields are completed and accurate before submission. Thank you for your cooperation.

1 (587) 576-3512

Individual Residential Program
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.

Please use this check box to assess your level of need on a scale of 1 to 5Please use this check box to assess your level of need on a scale of 1 to 5Please use this check box to assess your level of need on a scale of 1 to 5Please use this check box to assess your level of need on a scale of 1 to 5Please use this check box to assess your level of need on a scale of 1 to 5Please use this check box to assess your level of need on a scale of 1 to 5Please use this check box to assess your level of need on a scale of 1 to 5
Emergency Contact Info
Marital Status
Housing Status
Source of Income
Please select one of the following
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?
Do you have any medical conditions that require special accommodation?
Addiction History
Have you been to treatment before?
Mental Health: Do you have any psychiatric diagnoses?
Please check all that apply:
Do you have a history of any of the following?
Have you ever been hospitalized for psychiatric care?
Opiate Replacement Therapy
Are you currently on an opiate replacement?
What are you taking?
Type of substance(s):
Do you have any communicable diseases? Required
Legal
Do you have outstanding legal charges?
Do you have any upcoming court dates?
Do you have history of violent related charges?
Domestic Abuse/Trauma History
Is there a history of domestic abuse in your immediate family?
Do you have a history of domestic abuse against yourself?
Have you been abusive in DV relationships?
Family Dynamics
Are you pregnant?
Do you have children?
Post Treatment Plan
Do you have a plan for housing? Required
Goals
Referral Source
Please choose: Required
Please ensure to fill out the next page and click "submit" to send in your application
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Calgary, Alberta

587-891-8339

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©2023 by Alcove Recovery

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