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Phone: (780) 666-6223
Intake Form Careers

Intake Form

Welcome! Please fill out the form below to help us get to know you.

Addiction is an ongoing challenge, and we are here to help. Once submitted, we will give you a call and set you up with a recovery coach who will be your point of contact throughout your journey.

Your Name

Please enter your email so we can get in touch.

Birthday
9 characters left
Applied to Treatment Center
Okay to leave voicemail
Over 18
Currently Taking Medication?
Diagnosed with mental health condition?
Diagnosed with a medical condition?
Has Been Hospitalized
Currently Suicidal?
Has Attempted Suicide
Been to Treatment?
Consent to Contact Emergency Contact
Currently in VODP?
Alternate Phone Reliable?
Has Been Having Suicidal Thoughts
Treatment Was Completed
Has Overdosed?
Alberta Health Care Card?
Immediate Risk Of Harming Self/Others
On Treatment Centre Waitlist
On Recovery Community Waitlist
Consent - Contact Doctor and Therapist
Opioid Replacement Therapy?
Member of LGBTQ2S+ Community
I Self-Identify As An Indigenous Person
Private Insurance

Questions? 
We’re happy to hear from you!

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