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Sober Living Application

This application is for individuals seeking supportive sober living accommodations. All information submitted through this application is treated as confidential.

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Applying from a correctional facility or treatment centre? You can still complete this application. A caseworker, support worker, or family member can also fill it in on your behalf.

Applicant Information

Legal Full Name

Phone Number

Date of Birth

Day

Month

Year

Email Address

Address

Gender IdentityMaleFemaleNon Binary

Primary Language

Contact Consent

Yes, I consent to be contacted at the information provided.

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 Program

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?

Income

Please provide your monthly income.

Monthly Income AmountEnter the amount received each month, before deductions.

We acknowledge the traditional lands and territories of the Indigenous Peoples who have lived on and cared for these lands since time immemorial. We are located on Treaty 6 Territory and within the historic Métis homeland, including the North Saskatchewan River, Lesser Slave Lake, and Lower Athabasca River territories. We acknowledge and respect the histories, languages, and diverse cultures of First Nations, Métis, and Inuit peoples, and we are grateful for their ongoing contributions that enrich our communities.

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Shaganappi Recovery Solutions Inc.
Supportive sober living serving Edmonton and surrounding area, Alberta
587-433-2166