Alpha House
647 Broadview Ave
Toronto  Ontario  M4K 2N9


Phone: (416) 469-1700,
Email: apply@alphahousetoronto.ca
Referral Type:
Create a New Referral New Referral

APPLICATION FOR RESIDENCE

 

IMPORTANT!

                                                          YOUR APPLICATION WILL NOT BE PROCESSED UNTIL YOU HAVE FOLLOWED THE INSTRUCTIONS BELOW.


Complete this application fully and submit. 

Fill out the Consent to Release section, so that we may communicate with the residential treatment program to which you are registered.

Write in your OHIP number

Medications and Legal Conditions need to be 100% accurate. 
Incorrect or undisclosed information will result in cancellation of your admission either in advance or on the day of your admission. 

Call in on Monday from 12-2pm to speak with our Admission Coordinator, at 416-469-1700. You will not be added to the waitlist until you have spoken with him. After that, please call every Monday between 2pm and 4pm. Calls received after 4 pm will not be eligible for check-in that week. 
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Referral:
Alpha House Application - External Referral ID
Date: 2025-06-15 10:18
Status: Draft
Attachment(s):
( Max File Size is 256 MB )
TIP:To select multiple files, hold down the CTRL or SHIFT key while selecting
Admission Checklist
  1. Clients must graduate from a recognized treatment program in order to be eligible for Alpha House. Client must present grad certificate/letter of completion to Admissions
    Coordinator before admission will be granted.
  2. Graduation date is set for exactly 3 months from admission, extensions granted on case-by case basis.
  3. For the first 30 days clients must attend all in house classes/case management, cannot work, go to school, etc. After first 30 clients must continue to attend 3 mandatory evening classes and case management.
  4. Clients must test negative for all substances, no exceptions for THC.
  5. Clients must have written confirmation of the necessity of taking any drugs that fall under the narcotic category (benzodiazepine, stimulant, etc.) Dr. must confirm there is
    no safe alternative. 
  6. Opioid replacement clients on Methadone must be interviewed separately by our executive director, this will be arranged prior to admission by Admissions Coordinator. 
  7. Restricted medications include: Nabilone, THC based medications, Opiates such as (Kadian, Tylenol 1,2 or 3). Clients taking these medications are not eligible. 
  8. Clients must complete their first call in order for their application to be processed. Client must contact Admissions Coordinator every Monday between 2pm-4pm. 2 consecutive missed call-ins will result in the client being removed from the waitlist.
  9. Clients facing criminal charges or who are involved in the criminal justice system must sign a consent to release for Alpha House staff to be allowed two-way communication
    between AH and all legal representatives, court officials, etc. All disclosure, summaries, bail/probation/parole orders must be presented to Admissions Coordinator.
  10. Clients must explain any process/behavioural addictions they suffer from during the check-in stage so AH case manager will be fully informed upon admission.
 
Hide/ShowCLIENT INFORMATION
First Name
 
Last Name
Alias/Last Name at Birth
Alias / AKA:
DOB
Select Date Clear Date
Gender
Current address:
City
Postal Code
Province
Home/Other Phone:
Permission to call?
Phone (Home/Main)
Cell Phone:
Permission to call?
Phone (Alt)
Email
I identify as Indigenous (status or non-status)?
Health Card #:
Today's Date:
Select Date Clear Date
Previous residence at Alpha:
Clean/ Sober Date:
Select Date Clear Date
If employed, do you work overnights?:
Referral Information
Referral Source:
Reason(s) for the referral:
What type of bed you are applying for?
Ministry Funded
Paid service Bed
HART Hub Bed
Hide/ShowEMERGENCY CONTACT
Relationship to you:
 
Name of emergency contact:
Address:
Phone:
Permission to call?
Hide/ShowLEGAL STATUS
Are you currently involved in any legal matters?
If Yes, please explain:
Are you listed with the Ontario Sex offender Registry?
If Yes, please explain:
History of Violence?
If Yes, please describe:
(Including weapons/assault/robbery convictions, domestic violence, etc.)
Are you currently on:
bail
parole
probation
other
not applicable
If Other:
Describe your conditions, if any:
Hide/ShowSOURCE OF INCOME
What is your main source of income?
Employment
OW
ODSP
Family Support
Savings
Other:
 
Hide/ShowMEDICAL HISTORY
Do you have any major or chronic health problems?
If Yes, please provide details:
Do you have sleep apnea or chronic snoring?
If you have apnea do you have a CPAP machine?
Do you have any mobility issues?
 
Allergies?
(food, animals, pollen, etc.)
Hide/Show Medication(s) (dummy_group)
Delete

Please list all current medications below:

Please list all medication you are currently taking and the dosage. 

(Please note) Medications prescribed are required to be taken as prescribed and can only be changed when approved by both an approved physician and our clinical team. Benzodiazepines or drugs of misuse will require a letter from a physician or Psychiatrist stating there are no reasonable alternatives and no history of misuse. 

Medication:
Dosage:
Date you started taking medication:
Select Date Clear Date
Have you ever misused this medication? (Any use other than what the label stated)
Yes
No
Hide/Show Medication(s) (1)
Delete

Please list all current medications below:

Please list all medication you are currently taking and the dosage. 

(Please note) Medications prescribed are required to be taken as prescribed and can only be changed when approved by both an approved physician and our clinical team. Benzodiazepines or drugs of misuse will require a letter from a physician or Psychiatrist stating there are no reasonable alternatives and no history of misuse. 

Medication:
Dosage:
Date you started taking medication:
Select Date Clear Date
Have you ever misused this medication? (Any use other than what the label stated)
Yes
No
Add Section Add Medication(s)
Hide/ShowMENTAL HEALTH INFORMATION
Have you ever been diagnosed with a mental health disorder?
Are you currently receiving professional help to manage your mental health?
Mental Health Professional's Name and Phone
 
Have you ever been hospitalized for mental health?
If Yes, date of last hospitalization?
Select Date Clear Date
Description of events:
 
Have you ever attempted suicide?
If Yes explain:
(When, how many times, last attempt):
Do you currently have thoughts of suicide or self-harm?
Hide/Show Diagnosis (dummy_group)
Delete
Diagnosis:
When:
By Whom:
Hide/Show Diagnosis (1)
Delete
Diagnosis:
When:
By Whom:
Add Section Add Diagnosis
Hide/ShowSUBSTANCE USE HISTORY
Psychoactive Drug History Questionnaire
Drug Type: Cocaine/Crack
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Crystal Meth/ Speed/ Other Stimulants
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Cannabis: hash/ weed/ marijuana/ oil
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Benzodiazepines: Valium/Ativan/Clonazepam/Librium/etc.
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Barbiturates: (Phenobarbital, Seconal, etc.)
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Heroin/opium
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Prescription Opioids: Fentanyl / Dilaudid/Demerol/ Percocet/etc.)
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Alcohol
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Over the counter codeine reparations: (T1/T3/ Cough medications, etc.)
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Hallucinogens: LSD/DMT/STP/PCP/Magic Mushrooms)
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Glue/Gasoline other inhalants
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Tobacco: (cigarettes, cigars, chew, snuff etc.)
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Drug Type: Other Psychoactive drugs.
Used in Last 12 Months?
Yes
No
Frequency of use. (ex. daily, binge, 2 times per week, etc.)
Last day of use
Select Date Clear Date
Route of administration (smoke, snort, I.V.)
Hide/ShowTREATMENT INFO
Are you currently in a Residential Treatment Center:
If Yes, Agency Name:
Graduation Date:
Select Date Clear Date
If No, Agency Name:
Graduation Date of Last Treatment Center:
Select Date Clear Date
If you are registered for Residential Treatment, but are not yet attending, please list the name of the center and your intake date:
Hide/ShowGAMBLING/ SEX/ PORNOGRAPHY/ GAMING /FOOD
Do you have any behavioural addictions (Gambling, Sexual, Gaming, Pornography, Food):
If so, please explain:
Hide/ShowAPPLICATION CHECKLIST
I have:
completed the application fully
provided my OHIP Number
signed the Consent to Release section
Consent to Disclose Personal Health Information Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA)
For your treatment centre:
I confirm that this application is complete and truthful. I am aware that should there be medications or other information missing it may jeopardize my admission.
I,
authorize
(Name of health information custodian)
to disclose
my personal health information to Alpha House Recovery Community
(Print name and address of person requiring the information) I understand the purpose for disclosing this personal health information to the person noted above. I understand that I can refuse to sign this consent form.
Name:
Signature:
Date:
Select Date Clear Date
?
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