Restore Program- Application

Alycol is a name created to represent our directors two primary driving forces for change, her children. Alycol is a full-service health clinic that incorporates psychology, addictions, massage and acupuncture. We expect all our staff to be trauma informed and human welcoming. We don't believe in accepting we believe in celebrating humans as they are and being their biggest champions of change. On that note, Welcome Human!

Please be aware that the information requested below is optional and is used to determine whether the Alycol Restore Program is the most suitable resource. The information will be kept confidential and will only be retained if you are accepted into the program.

Please know that if we are not able to accept you into the Restore Program, we will provide alternative supports in your community. We will do all we can to ensure you are not alone in this journey.

Your Name

Email address

Number

Briefly Tell Us About You

If you are comfortable telling us, do you identify or connect with the following? This question is ONLY used to ensure we make the best fit with our interns and to ensure you are supported and celebrated for being such an incredible human.

Indigenous Peoples Community

2SLGBTQIA Community

Poly Community

Kink Community

People of Colour Community

Other

Services Requested

I am able to attend in-person sessions at the Alycol office in Spruce Grove

I am only able to attend virtually

I can attend in person or virtually

How many humans are in your home (including children)?

What is your annual household income?

<$20,000 $20,001- $40,000 $40,001- $60,000 $60,001-$80,000 $80,001- $100,000 >$100,001

Do you have private insurance coverage? This is not an exclusion criteria.

Where do you reside?

Spruce Grove or Parkland County Stony Plain Edmonton Other

Please describe your current mental health struggles.

On a scale of 1 to 10, how satisfied do you feel in your world?

On a scale of 1-10, how ready are you to engage in psychological supports?

Please describe your relationship with substances such as drugs or alcohol.

Do you have, or have you had, plans to kill yourself?

Which supports do you currently have in place?

Family Doctor

Psychiatrist

Psychologist

Addiction Counsellor

Healthy Family Supports

Other

Restore Program sessions are maximum $50 per hour but depending on circumstances that amount could be reduced. Please consider your current situation and determine what amount you may be able to budget for psychological supports from our Master's Intern. Please know that pro-bono sessions are limited so please put your maximum but also state whether we need to look at no-cost alternatives. Remember, we are here to help connect you to resources and supports.

How often would you like to attend sessions? Please consider your budget when answering this question.

Weekly Bi-weekly Monthly

Consent and Understandings

I consent to Alycol Health reviewing the information provided above with clinical staff as needed for program application.

I understand that all Alycol Health staff are mandated to maintain the strictest confidentiality

I understand that there is no guarantee of being accepted into the program and that that may be determined based on intern availability and clinical capacity.

I understand that the intern is supervised by Vanessa Foley, R. Psych.

Your information will be encrypted.