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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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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

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.

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
Support Worker
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 allergies?
Do you have any medical conditions that require special accommodation?
Do you have any mental health conditions?
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?
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?
Father involved:
CFS involved:
Regular visits:
Post Treatment Plan
Do you have a plan for housing?
Goals
Referral Source
Please choose:
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