* Denotes Required Field* Title
* Date
* First Name
* Middle Name
* Last Name
* Date of Birth
* Hair Color
* Eye Color
* Height
Active Phone Number () -
Email Address
* City
Address
Alberta Health Care Number
* Do you struggle with addictions?
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?
* What is your current living situation?
Shelter Street With family or friends Rent Own Incarcerated Other 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?
* Do you have a history with addictions?
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?
p*rnography
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.
What we offer as part of our 6-month program:
* How do you feel the above services will help you?
The cost to attend the 6-month program is as follows; monthly rent is $500/month, a one-time damage deposit fee of $350, and a one-time fee of $100 for program supplies.
List your primary source(s) of income and the amount received per month. Check all that apply.
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?
* Do you have any outstanding debts?
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
Who does the child reside with?
Name
Date of Birth
Who does the child reside with?
Name
Date of Birth
Who does the child reside with?
Name
Date of Birth
Who does the child reside with?
* Is child protection currently involved with the family?
Describe any current custody issues:
MENTAL HEALTH STATUS AND COGNITIVE CONCERNS * Do you have a diagnosed mental health disorder?
Please select any diagnosed mental health disorders that apply to you.
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.
* Do you have concerns about any potential "undiagnosed" mental health disorders?
If you answered yes to the above, please explain.
* Do you have a history of suicide attempts?
Are you currently thinking about committing suicide? If yes, please explain.
* Do you have a history of self-harm?
Are you currently thinking about self-harming? If yes, please explain.
LEGAL HISTORY * Are you currently under any legal supervision?
Please indicate offence(s) and supervision requirements:
PLEASE SEND A COPY OF ANY AND ALL CHARGES TO APPLY@RISINGABOVEGP.COM
* Do you have a history of verbal aggression towards others?
* Do you have a history of weapon use?
* Are you currently taking medication?
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.
