Transitional Housing Intake Form – Brantford Native Housing

Brantford Native Housing Transitional Housing Program

Ojistoh House, Karahkwa House, Odehaot House
318 Colborne Street East
Brantford, ON N3S 3M9
Phone: (519) 756-2205 x 226 or x 235
Fax: (519) 756-1764

Background

The Transitional Housing Programs are offered through Brantford Native Housing. This program is offered to Indigenous men (Karahkwa House), women ages 16+ (Ojistoh House) and families (Odehaot House) who are experiencing homelessness or at-risk of homelessness. Residents can stay in the Transitional Housing Program for up to one (1) year.

Please note; The Transitional Housing is not a shelter and is not intended to provide emergency housing in any way. Residents will be expected to participate in programming and maintain abstinence from all alcohol and recreational (mood altering) drugs while residing in the Transitional Housing Program.

Once we receive the completed application forms, a Housing Outreach Worker will schedule an intake interview with you.

Eligibility Criteria

Ojistoh House – At least 50% of the family (female Applicants bringing children) must be of Indigeonous ancestry.
Karahkwa House – Male Applicants must be of Indigenous ancestry.
Odehaot House – At least 50% of the family must be of Indigenous ancestry.
Applicant must be in need of housing due to homelessness or at-risk of homelessness (i.e., living in a shelter, temporarily staying with family or friends, etc.)
Applicant must be 16 years of age or older.
Applicant must be eligible for Ontario Works, ODSP or other income programs, if not working or attending school or a training course.
Applicant must be committed to paying service fees;
Applicant must be committed to connecting with community resources and moving toward an independent and healthy lifestyle.
Applicants must agree to sign our Consent to Obtain Information form with the referring community service agency and other service providers the Applicant is working with.

Transitional Housing Program Application Form

House

Ojistoh House (Female)

Karahkwa House (Male)

Odehaot House (Family)

1. Referring Agency Information

Name of Agency

Name/Position:

Address:

Telephone/Fax/Email:

2a. Applicant Information

Applicant Name:

Date of Birth:

S.I.N:

Native Ancestry(Required)

First Nations

Indigenous

Metis

Inuit

Upload Proof of Indigenous Identity(Required)

Drop files here or

Max. file size: 128 MB.

Applicant Address:

Applicant Band and Number:

Telephone/Email:

Are you applying with a Co-Applicant?(Required)

Yes

2b. Co-Applicant Information

Co-Applicant Name (if applicable):

Date of Birth:

S.I.N:

Indigenous Ancestry(Required)

First Nations

Indigenous

Metis

Inuit

Upload Proof of Indigenous Identity(Required)

Drop files here or

Max. file size: 128 MB.

Co-Applicant Band and Number:

Co-Applicant Address:

Telephone/Email:

3. Dependents

Does the Applicant(s) have any dependents?

Yes

1. Name

Indigenous Ancestry

Gender

Age

Date of Birth

2. Name

Indigenous Ancestry

Gender

Age

Date of Birth

3. Name

Indigenous Ancestry

Gender

Age

Date of Birth

4. Name

Indigenous Ancestry

Gender

Age

Date of Birth

5. Name

Indigenous Ancestry

Gender

Age

Date of Birth

4. Education

Applicant Highest Level of Education Completed(Required)

Some High School

High School Graduate

GED

Some College

College Graduate

Some University

University Graduate

Technical/Trade Certified

Training

Co-Applicant Highest Level of Education Completed(Required)

Some High School

High School Graduate

GED

Some College

College Graduate

Some University

University Graduate

Technical/Trade Certified

Training

5a. Applicant Work History

Is the Applicant currently employed?(Required)

Yes

If no, What is Applicant's source of income?(Required)

Applicant Employer Information

Employer

Address

Telephone/Email:

Position

Work Hours

Salary/Wage per hour

Does the Applicant have an up-to-date resume?(Required)

Yes

Does the Applicant want to work?(Required)

Yes

Does the Applicant understand that she/he is required to pay service fees (shelter portion of OW or ODSP or 25% of income) to stay in the Transitional Housing Program?(Required)

Yes

5b. Co-Applicant Work History

Is the Co-Applicant currently employed?(Required)

Yes

If no, What is Co-Applicant's source of income?(Required)

Co-Applicant Employer Information

Employer

Address

Telephone/Email:

Position

Work Hours

Salary/Wage per hour

Does the Co-Applicant have an up-to-date resume?(Required)

Yes

Does the Co-Applicant want to work?(Required)

Yes

Does the Co-Applicant understand that she/he is required to pay service fees (shelter portion of OW or ODSP or 25% of income) to stay in the Transitional Housing Program?(Required)

Yes

Applicant(s) Questionnaire

1. How long has/have the Applicant(s) been homeless?

2. Is the Applicant(s) able to complete daily living chores?

3. Does/Do the Applicant(s) have any disabilities

4. Does the Applicant(s) have any children that are not in their care and will not be staying with the Applicant?

Yes

5. Where is the Applicant(s) presently living?

Shelter

Family/Friends

Hotel/Motel

Other

6. Are there any safety issues/concerns regarding current or past intimate relationships?

Yes

if yes, is there

Restraining Order

Peace Bonds

Custody Orders

CAS Conditions

Other

Please explain:

7. Is the Applicant or Co-Applicant on Probation or Parole?

Yes

If Yes, who?

Who is the Probation/Parole Officer?

Contact Number

8. What other agencies/service providers is the Applicant currently working with?

Ontario Works

CAS

Probation & Parole

Mental Health Supports

Counselling

Legal Services

Public Health Services

Training Program

Employment Services

Other

9. What wellness steps has the Applicant taken recently?

Support System

Therapy/Counselling

Anger Management

Group Therapy

Cultural Activities

Other

Is the Applicant on the Methadone Program?

Yes

If yes, who?

If yes, where does the Applicant access the meds and who manages their participation?

11. What goals does the Applicant want to work on?

12. Who does the Applicant include as support during crisis?

Include Name, Relationship & Contact Information for each individual

13. Emergency Contact Persons

Include Name, Relationship & Contact Information for each individual

Health Information

1. When did the Applicant(s) last see a Doctor?

Doctor

Phone #

Address

2. Does the Applicant(s) have any life threatening allergies?

Food

Environment

Medication

No Known Allergies

If yes, please explain

3. Does the Applicant(s) carry an Epi-pen for allergies?

Yes

4. Is the Applicant(s) currently in any type of treatment or counselling for emotional or mental health problems?

Yes

If yes, where?

5. Please add any additional information that will assist our understanding of the Applicants' needs.

Brantford Native Housing
Consent to Obtain and Disclose Information

What is “Personal Information?”

Personal information includes any factual or subjective information, recorded or not, about an identifiable individual. This includes information in any form, such as:

age, name, social status, income, assets, residency status, Indigenous ancestry, rent payment record, etc;
opinions, comments, evaluations and observations.

Collection and Use of Your Personal Information

Brantford Native Housing staff will collect, retain and use the personal information provided by you in this form and its attachments for the following purposes:

considering your application for residential eligibility;
verifying the information that you have provided in your application and its attachments relating to the administration and processing of your application for residency;
calculating your rent and the collection of your rent;
meeting legal and regulatory requirements arising out of or relating to your residency;
for the use of Brantford Native Housing’s auditor to verify our financial records;
for the purpose of contacting necessary services on your next-of-kin in case of emergency;
for the purpose of cooperative effort in service provision and case management;
for the purpose of making repairs or renovations to the residential unit.

Brantford Native Housing will disclose the personal information provided by you in this form to the following parties for the purposes as outlined above:

to any social agency providing any form of assistance to you, or other government subsidy under the Ontario Works Act, 1997, the Ontario Disability Support Program Act, 1997, or the Day Nurseries Act, or any government department responsible for social housing programs under the Residential Tenancies Act, or Brantford Native Housing’s housing portfolio operating agreement;
to the Government of Canada, a department, ministry or agency of it, without further notice to me if the information is necessary for the purposes of administering or enforcing the Income Tax Act (Canada), the Immigration Act; the Health Protection and Promotion Act and the Child and Family Services Act;
to any agent working on behalf of Brantford Native Housing for the purpose of complying with the Residential Tenancies Act;
to any agent/contractor working on behalf of Brantford Native Housing to make repairs or improvements to the facility or unit;
to relevant agencies or next-of-kin in case of emergency;
to relevant agencies to assist in the cooperative effort and delivery of services, and inclusive of the Mental Health Act;
to credit bureaus, other business or individuals that provide credit or rental history information about you;
to the City of Brantford – Housing Department for any damage or rental arrears left after vacating the residential unit and to Financial Institutions for the collection of rent;

The Executive Director of Brantford Native Housing, located at 318 Colborne Street, Brantford, Ontario, N3S 3M9, 519-756-2205 can answer questions and respond to complaints about the collection, use or disclosure of the information.

Consent

I authorize and agree that Brantford Native Housing may collect, use and disclose the personal information that I have provided in this form and its attachments as described above as well as dispose of personal information. I understand and acknowledge that, in addition to the foregoing, Brantford Native Housing, will also collect and use and disclose my personal information as required for the purposes and intentions of meeting legal obligations and in the performance of duties as/or permitted by law.

Applicant Signature

Date

Co-Applicant Signature

Date

Referring Agency Signature

Date

Brantford Native Housing Transitional Housing Program

Ojistoh House, Karahkwa House, Odehaot House 318 Colborne Street East Brantford, ON N3S 3M9 Phone: (519) 756-2205 x 226 or x 235 Fax: (519) 756-1764

Background

Eligibility Criteria

Transitional Housing Program Application Form

1. Referring Agency Information

2a. Applicant Information

2b. Co-Applicant Information

3. Dependents

4. Education

5a. Applicant Work History

Applicant Employer Information

5b. Co-Applicant Work History

Co-Applicant Employer Information

Applicant(s) Questionnaire

Health Information

Brantford Native HousingConsent to Obtain and Disclose Information

What is “Personal Information?”

Collection and Use of Your Personal Information

Brantford Native Housing will disclose the personal information provided by you in this form to the following parties for the purposes as outlined above:

Consent

Ojistoh House, Karahkwa House, Odehaot House
318 Colborne Street East
Brantford, ON N3S 3M9
Phone: (519) 756-2205 x 226 or x 235
Fax: (519) 756-1764

Brantford Native Housing
Consent to Obtain and Disclose Information