Materials and Application Downloads

On-line Application Form

First Name
Last name
Email
Phone
Emergency Contact
Birth Date
Is this application for
Calgary or Edmonton
Are you:
Male
Female
Homeless	YesNo
Aboriginal	YesNo

What is your MAIN Addiction?

What else are you addicted to?

What drugs have you used in the past year?

Do you have a gambling addiction?

Have you had treatment for your addiction in the past year?
Name of Treatment Centre
Length of Treatment
Date of Compltetion

When did you last:
Use Alcohol
Use Drugs
Gamble

What Program Meetings will you attend each week?

AA
NA
CA
GA
Other

Do you have any special needs or disablilties we should be aware of?

What medications are you on?
Medication	Dosage per day	How long have you been taking this med





Doctors Name
Location

Are you ready to transition back to work, school, or volunteer?

Do you have a job already?
Will you be looking for work?
If neither of the above, what will you be doing?

What type(s) of work have you had experience in?

Do you have a criminal background or any pending charges?

Have any criminal charges or charges involving violent behavior
Currently on probation or house arrest
Have a pending court date
Committed any sex crime

Current financial assistance?

Social Services
E.I.
W.C.B.
A.I.S.H.
Other

Have you lived in Oxford House before?

If Yes:
When
House
Reason for Leaving

Do you have any history of communicable diseases?

NOTE: You will still be required to complete the full four page application, before acceptance. It can be downloaded from this website, faxed to you or filled in at one of our two offices.

Additional Comments