If you are seeking counselling and shelter,
use the Residential Application linked here.

Non-Residential Application

    Non-Residential Application

    Submit options:
    Complete online, email to womenscounsellor@alphahouseproject.ca,
    fax to 204-254-2602, or mail to Alpha House P.O. Box 37015 RPO St. Vital Centre Winnipeg, MB R2M 5R3

    Name

    Email

    Date of Birth

    Day

    Month

    Year

    Phone Number: Home/Cell

    Is it safe to leave a voicemail at this number?

    Current Address (at time of application)

    How long have you lived at this address?

    Is this current address:

    Do you currently live with your abuser?

    Children Information


    Please provide information about your children (names, genders, birthdates, grades, and locations):

    Do you require childcare during your counselling sessions?

    If yes, do your children have any allergies, serious health, or medical problems? Please list:

    Health Information

    Do you have any serious health/medical problems?

    Are you currently struggling with your mental health?

    Do you struggle with thoughts of suicide?

    Have you ever struggled with substance use?

    What coping strategies do you use? How do you take care of yourself emotionally?

    Safety Information


    What protection planning/safety measures do you have in place?
    (e.g., new phone, changed email/social media, new address/school, secured documents)

    Please provide information about the abusive partner (name and address):

    How long have you been in/were you in the relationship?

    Are you currently in danger?

    Do you have a protection order or a prevention order?

    Has your abuser ever used stalking behavior such as monitoring your emails, social media, tracking your phone, or physically following you/your children?

    Have you ever previously left your partner because of abuse?


    If yes, please provide details of when you left, where you stayed, and length of time away:

    How do you think Alpha House non-residential counselling can help you and your children? What are some of your counselling goals?

    Availability


    Our program runs M-Th 9am-4pm and F 9am-2:30pm. Please describe your availability during these hours:

    I HEREBY AGREE TO THE EXCHANGE OF INFORMATION BETWEEN THE REFERRING AGENCY AND ALPHA HOUSE RELATING TO THE PROCESSING OF THIS APPLICATION

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    Date

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