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Ready to discover what sober life can be?

Fill out our application form to apply for your bed today. Please answer each question with as much detail as possible so we can get to know you. We’ll be in touch with you soon!

Please use the Contact Us tab to request a printable application form if you require a printed form.

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Consent For Assessment

Terms and Conditions(Required)

Informed Consent for Assessment

Purpose: For you to understand the process and nature of our treatment program as well as the associated risks and benefits, so you can make an informed decision about whether or not to participate.

Moving into a residential treatment centre is not an easy transition for anyone seeking to recover from addiction. Engaging in recovery services takes a lot of courage and provides you with the opportunity to discover much about yourself and your behaviours. This may be your first experience, and it is important for you to understand what treatment is about.

SAM Philosophy and Services

Southern Alcare Manor is a 3rd Stage model of treatment and is based upon abstinence from using addictive substances and materials. Our program is designed to consist of mandatory attendance at group sessions during the daytime and some evenings, continued support in transitioning back into society through obtaining/returning to work or education and finding suitable housing and services to aid daily living.

While a resident of SAM you will be assigned a Recovery Coach. This Staff member will be available to help you in navigating your way through the maze of services available in the community. Your Recovery Coach will help you determine your recovery plan and lead your progress reviews to keep you focused on your goals and lifestyle commitments.

You will also be assigned a therapist who will assist you with any mental health concerns and provide professional help in accomplishing any desired changes you would like to make in your life. Your wishes and goals will be considered because the philosophy of SAM also includes the concept of “meeting you where you are at” and helping you get to where you would like to be as you exchange old patterns for new ones. Our Staff are connected with other services available including, but not limited to psychiatrists, medical providers, pharmacies, therapy specialists, etc. We work hard to ensure you become connected with any needed services.

Treatment Risks and Benefits

Recovery Treatment is different than just going to a self-help meeting. Our services have specific goals, set largely by you, and though our services may be supportive they will also challenge you. Sometimes you might feel annoyed, tired or upset following a group session, or in having to participate in house chores. This can happen as you incorporate new ways of living and thinking and filling blocks of time formerly filled by substance-seeking behaviours. You will also be living in a communal setting with other adults as roommates, or dinner mates in the dining room, or sharing a television in the evening with others who don’t have your same tastes and preferences. As you progress through your time in our program and accumulate clean days you will experience changes in your beliefs and activities or relationships that may have unexpected results. Usually these changes are very positive in the long-term, but it may be difficult to experience them as they are occurring.

You may be exposed to specific psycho-educational groups and ideas that are new to you. If you have any questions about these things it is important that you ask them. It is also important for you to know that you have the right to terminate your participation in our program at any time. Our program is safe, with doors that lock and prevent the outside influences from getting in. These doors are not locked to keep you in. You may leave the program at any time and attend alternative programs or attempt to recover on your own. There are similar programs in Medicine Hat, Calgary, Red Deer, Edmonton and in other communities throughout the province. There is also a Detoxification centre in the Lethbridge hospital, one in Fort McLeod, a 2nd Stage recovery centre east of Lethbridge, and a supervised consumption site in the city. There are also various services in Lethbridge that offer services you may access on your own. Feel free to ask for referral information.

Program Costs

The only things one needs to pay for individually include toiletries, tobacco, towels and outside entertainment. We prefer that personal belongings be kept to a minimum. A good quality pillow may also be useful if one has preferences.

Conflict of Interests

SAM Staff have limits on the types of interactions they may have with residents. Professional boundaries must be maintained. Staff will not pursue relationships with residents other than those required in the provision of services. Staff will not give legal, medical, financial or other professional advice. Staff will not have romantic, friendship, or sexual relations with clients. Staff will neither give nor accept gifts from residents. Staff will not attend personal parties or other events sponsored by residents or their families and friends.

It is important for residents to feel safe while at SAM. If there is a perceived conflict with Staff, or the assigned Recovery Coach or Therapist, you have a right to request a change, or even a referral to another agency.

It is also important for Staff to feel safe in their work, and their concerns will be considered if they should begin to feel uncomfortable in caring for you. This can occur if their personal values, experiences or reactions interfere with their ability to provide you with the best care possible.

It is very important that everyone realize this is a residential program, where adults from disparate backgrounds live and work. Procedures will be enacted to ensure the safety of all involved. Incompatibilities will be dealt with in the least restrictive way possible.

Resident Consent to Treatment

• I have read the Informed Consent for Services document, had enough time to consider it carefully, asked any questions that I need to, and understand it.
• I understand that I will be assessed for progress at intervals.
• I understand the SAM philosophy of working with me where I am.
• I understand the SAM philosophy of abstinence.
• I understand the benefits and risks of participating in this program.
• I understand that my behaviours must be compatible to the program and cooperative in nature.
• I understand that any conflicts with Staff or other residents will be investigated and dealt with in the least restrictive way.
• I understand that there are alternate services available to me.
• I understand that I may be referred to appropriate services.
• I agree to participate in the recovery program offered at Southern Alcare Manor.

I consent to the assessment terms above.

Your Personal Information

Your name

First Last

Your email address(Required)

Your phone number

Age

Gender

Province

Health care number

Are you indigenous or have status?

What level of education have you completed?

Are you comfortable reading and writing?

Yes

Is this something you would like help with?

Yes

Substance Use and Treatment History

What mood-altering substances (including alcohol, drugs, medications, non beverage alcohol and over-the-counter medicines) have you used in the past year?

What date was your last use of alcohol or drugs?

Do you have a history of gambling?

When were you last in detox?

If you are in a Treatment Center, when do you graduate? If not, when and where did you complete your last treatment program?

Who is your addiction counsellor in treatment?

Addiction counsellor phone number

Addiction counsellor email

Can we have your permission to discuss your discharge plan from that treatment center?

Yes

Recovery and Medical History

Is there a recovery plan that you are currently following?

Have you ever been hospitalized due to your use?

Yes

When and where?

Have you ever overdosed?

Yes

When was the most recent overdose?

Do you have a mental health diagnosis?

Yes

Please specify

Are you taking any medication including Suboxone, Sublocade, Naltrexone or Methadone?

Yes

Which ones and dosage? Please include date started.

Physical Health and Employment

Do you have any open wounds, skin infections, or have you had any recent surgeries?

Yes

Please specify

How is your current physical health?

Do you have any physical barriers we should know about?

Please specify

Where have you lived over the past year?

Have you been employed in the past year?

Yes

Are you still currently employed?

Yes

Do you have a military background?

Yes

Family, Trauma, and Referral Information

Have you ever been physically, emotionally, or sexually abused?

Yes

Have you had counseling for this abuse?

Yes

When was your counseling?

Have you been diagnosed with PTSI (Post Traumatic Stress Injury)?

Yes

Do you have any legal issues or court dates?

Yes

Please specify. What are your conditions?

Are you currently pregnant?

Yes

Do you have children?

Yes

Please list age(s) and first name(s)

Are you hoping to be involved with your children?

Yes

Is Child and Family Services involved?

Yes

Which office and/or worker’s name?

Please specify arrangement with children

Where are your children currently staying?

Who referred you to Southern Alcare Manor or how did you hear about us?

Is there anything not addressed here you have questions about?