* Denotes Required Field
* Title
* Date
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* First Name
* Middle Name
* Last Name
* Date of Birth
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* Hair Color
* Eye Color
* Height
Active Phone Number
( ) -
Email Address
* City
Address
Alberta Health Care Number
If yes, how much clean time do you have from each substance you use?
NO SUBOXONE OR METHADONE PERMITTED IN PROGRAM
* Why are you interested in being part of the Rising Above Program?
* What barriers/struggles are you currently experiencing in your life?
* What would you like to see changed in your life?
* Where were you born and raised?
* What is your ethnic background?
If you selected "other", please explain.
* Are you in good standing with your housing? (any unpaid rent, difficulties with landlord or roommates, in jeopardy of losing housing?)
Are you currently receiving support from Alberta Works, CRB, E.I., or any other funding stream?
What is the name of your financial aid worker?
What is the phone number for your financial aid worker?
( ) -
What is the email address for your financial aid worker?
Have you ever been evicted from a residence and why?
PLEASE CHECK ALL THAT APPLY AND INDICATE SINCE WHEN
Alcohol
Since when?
Crack/cocaine
Since when?
Ecstasy
Since when?
Heroin
Since when?
Gambling
Since when?
Meth
Since when?
Marijuana
Since when?
Prescriptions
Since when?
Fentanyl
Since when?
Food
Since when?
Nicotine
Since when?
GHB
Since when?
Pornography
Since when?
Sex
Since when?
Technology (gaming, phone, etc.)?
Since when?
* How much clean time do you have from all substances?
* Which addictions do you feel have the most influence/control over you? Please explain.
* How do you feel the above services will help you?
Employment
Amount?
Alberta Works
Amount?
Family or friend
Amount?
E.I.
Amount?
Aboriginal funding
Amount?
AISH
Amount?
Pension (CPP, OAP, Private)
Amount?
CRB
Amount?
No income
Amount?
Other
Amount?
If yes, please list the debt(s), amount outstanding and monthly payments.
FAMILY/SOCIAL NETWORK
* What is the current status of your family?
If yes, please complete the boxes below.
Name
Date of Birth
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2022
2023
2024
Who does the child reside with?
Name
Date of Birth
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2019
2020
2021
2022
2023
2024
Who does the child reside with?
Name
Date of Birth
Jan
Feb
Mar
Apr
May
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Jul
Aug
Sep
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Nov
Dec
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1995
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2000
2001
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2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Who does the child reside with?
Name
Date of Birth
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
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Who does the child reside with?
Describe any current custody issues:
MENTAL HEALTH STATUS AND COGNITIVE CONCERNS
Anxiety
Depression
Bipolar
Schizophrenia
Post-Traumatic Stress Disorder
Obsessive-Compulsive Disorder
Borderline Personality Disorder
Other
If you have selected any of the above diagnosed mental health disorders, please explain the struggles you face with this.
If you answered yes to the above, please explain.
Are you currently thinking about committing suicide? If yes, please explain.
Are you currently thinking about self-harming? If yes, please explain.
LEGAL HISTORY
Please indicate offence(s) and supervision requirements:
List all current medications.
RESIDENTIAL FEES
*
By checking this box, you understand the following fees are associated with our program.
$500.00 Rent per month (adjusted if mid-month, to be paid upon entry)
$350.00 Damage Deposit (to be paid upon entry)
$100.00 Program Supplies Fee (one-time fee, to be paid upon entry)
Participants buy their own groceries and make their own meals.
CLEAN TIME REQUIREMENT
*
By checking this box, you understand there is a mandatory requirement of 7-days clean from all drugs and alcohol. This includes all marijuana related products. Rising Above tests each individual before they are admitted. If you fail a drug or breathalyzer test, you will be denied entry into the program.
FAILED TEST RISK ACKNOWLEDGEMENT
*
By checking this box, I, the applicant, understand that if I fail my drug or breathalyzer test during admission, I will not be allowed into the program and accept all risks associated with the failed test. These risks may include difficulty finding transportation and accommodation, as well as potentially experiencing food insecurity.
CONSENT FOR RELEASE OF INFORMATION TO RISING ABOVE
*
By checking this box, you, the applicant, are agreeing to the release of information contained in the Rising Above application you're submitting. The applicant understands that persons, professionals, agencies or institutions named in this application may be contacted for additional information or documentation. This information will be used to determine if Rising Above is a suitable service for you and will assist in program planning if you, the applicant, are accepted into the program. You, the applicant, understand that your personal information may be disclosed to an employee, agent or contractor of the Rising Above Program, to verify your eligibility for the program or to monitor, assess and evaluate the results of the benefits and support programs in the Rising Above Program. By checking this box you're agreeing to the release of your information and confirming you're 18 years of age or older. You, the applicant, understand that all incomplete applications will not be considered.