Downloadable Pre-Treatment Housing Application

Pre-Treatment Application

Pre-treatment Housing Application – Please fax to 403-214-2047 or email to intake@oxfordhouse.ca

If you have any questions, please call 403-860-2094.

Pre-treatment housing in Calgary is a 4–6-week program that offers safe, stable accommodation for individuals waiting to enter addiction treatment. It provides structure, peer support, and a substance-free environment to help residents stabilize, access community resources, and prepare mentally and physically for treatment—reducing relapse risk and bridging the gap between detox and formal recovery programs.

Intake Days:
We are only accepting new intakes on Monday, Tuesday, or Wednesday.

Thursday intakes will only be accepted if Monday is a statutory holiday.

Medication ROI & Pharmacy Use:

Residents must complete the Medication Release of Information (ROI) form which will be sent to you during the application process
Medicine Place is our designated pharmacy
All prescriptions must be faxed to, and filled by, Medicine Place.
Effective immediately, we will not accept any medications from other pharmacies.
If a resident wishes to take previously prescribed medications to another treatment centre, we can store them in a locked cabinet. However, these medications will not be accessible to the resident while they are at Oxford House.

Prescription Handling:

Do not fill prescriptions prior to acceptance into Oxford House.
Instead, have the prescription faxed directly to Medicine Place to ensure timely communication.
Oxford House cut-off time for receiving all required documentation and prescriptions is 12:00 PM, Monday to Thursday.

Name

First Name

Last Name

Gender

Birthdate

YYYY

Are you homeless?

Phone

(###)

###

####

Alberta Healthcare #

What is your main addiction?

What else are you addicted to? Please indicate N/A if this does not apply to you.

What drugs have you used in the past Year?

What is the longest time you have been clean and sober?

Date of last drink?

YYYY

Date of last drug?

YYYY

List any treatment you have had in the past or are taking now for your addiction.

Pease include name, date of treatment and reason for leaving.

Which treatment centres have you applied to?

Are you currently in detox? If yes, when is your dicharge date?

Answer yes or no and discharge date if applicable

Do you have a gambling addiction?

Last Date Gambled. Please indicate N/A if this does not apply to you:

What is your ethnicity

Do you have any children?

Ages of children?

Gender and age of each child

Did an agency refer you? If so, please indicate which agency?

Answer yes or no and indicate agency if applicable

Please provide your emergency contact's name, address and phone number

Emergency Contact Information

What is your relation to them?

Emergency Contact Information

List all medications you are taking, including prescribed & non-prescribed. Please provide the medication, dosage, reason prescribed and date of prescription.

Do you have any special needs that we should be aware of? (Learning disabilities, difficulty with reading or writing, hearing difficulties, difficulties with stairs etc.)

Current Medical Condition (Recent injuries, surgery, etc.)

Any history and/or contact with communicable diseases?

Answer yes or no and explain if the answer is yes.

Physician's name and phone

Past or Present Convictions, Court Dates etc., indicate N/A if this does not apply to you

Legal Status

Are you facing any current charges? If so, what are the charges?

Legal Status

Parole or Probation Officer's name & phone # (Indicate N/A if this does not apply to you

By submitting your application you agree that you have read and understand that if accepted into an Oxford House, you agree to the terms of the Resident/Oxford Tenancy Agreement. A two-week notice is required when moving from your Oxford House home. Oxford House will conduct random drug testing. The nature of Oxford House requires immediate eviction of a resident member who is using alcohol or drugs including abuse of prescription drugs. Any member suspected of using alcohol or drugs, displaying disruptive behaviour or nonpayment of monies can be evicted by a majority vote of the house membership or by Support Worker. You agree that within 72 hours (3 days) of leaving a residence, voluntarily or otherwise, you will remove your personal belongings. I understand that I am required to sign the Oxford House Rules & Regulations and the Contract of Oxford House Residency prior to moving into an Oxford House. I also understand that any false answer on any of the above items is grounds for eviction from Oxford House and I consent to the release of any confidential information regarding my personal history, medical history, treatment, and/or any information deemed necessary by the Oxford House Foundation of Canada. This authorization and request is intended confidential for the specific purposes of the Oxford House Foundation of Canada only.

I agree to the terms