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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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If you can not use the form below and would like to submit the application by email or fax, please fill out this PDF and submit it through email at intake@alcoverecovery.ca or fax (403-242-3915). Please note that submitting online in the form below is most ideal.

1 (403) 984 2707

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.

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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?
Addiction History
Type of substance(s):
Marital Status
Are you pregnant?
Do you have children?
Please ensure to fill out the next page and click "submit" to send in your application
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