Kerry Gladue
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Referral Application

This application is for individuals seeking supportive sober living accommodations. All information provided is kept confidential.

Applicant Information

Legal Full Name

Phone Number

Date of Birth

Month

Day

Year

Email Address

Address

Gender IdentityMaleFemaleNon Binary

Primary Language

Emergency Contact & Next of Kin

This contact will be notified in case of an emergency.

Name

Relationship

Phone

Email Address

Do you consent to this person being contacted in case of Emergency?YesNo

Referral & Support History

Are you currently in a Treatment / Recovery Program?YesNo

Name of Progam

Date of Completion?

Month

Day

Year

List of Primary Substances

When is your clean date from all substances?

Month

Day

Year

Have you been in sober living before and if so where?

Medical & Clinical Information

Do you have a family physician? *YesNo

Name of Physician and Clinic? *

Are you currently taking any medications? *YesNo

Please list all medications *

Do you have any physical or mental health conditions we should be aware of?

Name of Pharmacy and Location

Alberta Health Care

Financial & Logistics

What is your current source of funding?

What is your file Number?

Are you First Nations, Metis, Inuit? *First NationsMétisInuitN/A

Please provide Treaty or Métis Number: *

What date would you like to move in? *

Month *

Day *

Year *

We acknowledge the traditional lands and territories of the Indigenous Peoples who have lived on these lands and taken care of them since time immemorial. We are on Treaty 6 Territory, as well as, the historical regional homeland of the Métis, which includes the North Saskatchewan River Territory, the Lesser Slave Lake Territory, and the Lower Athabasca River Territory. We acknowledge and respect the histories, languages, and diverse cultures of the First Nations, Métis, and Inuit and are grateful for their contributions that continue to enrich our communities.