Transitional Housing Intake Form 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 FormHouse Ojistoh House (Female) Karahkwa House (Male) Odehaot House (Family) 1. Referring Agency InformationName of Agency Name/Position: Address: Telephone/Fax/Email: 2a. Applicant InformationApplicant 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 Select files Max. file size: 16 MB. Applicant Address: Applicant Band and Number: Telephone/Email: Are you applying with a Co-Applicant?(Required) Yes No 2b. Co-Applicant InformationCo-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 Select files Max. file size: 16 MB. Co-Applicant Band and Number: Co-Applicant Address: Telephone/Email: 3. DependentsDoes the Applicant(s) have any dependents? Yes No 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. EducationApplicant 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 HistoryIs the Applicant currently employed?(Required) Yes No If no, What is Applicant's source of income?(Required) Applicant Employer InformationEmployer Address Telephone/Email: Position Work Hours Salary/Wage per hour Does the Applicant have an up-to-date resume?(Required) Yes No Does the Applicant want to work?(Required) Yes No 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 No 5b. Co-Applicant Work HistoryIs the Co-Applicant currently employed?(Required) Yes No If no, What is Co-Applicant's source of income?(Required) Co-Applicant Employer InformationEmployer Address Telephone/Email: Position Work Hours Salary/Wage per hour Does the Co-Applicant have an up-to-date resume?(Required) Yes No Does the Co-Applicant want to work?(Required) Yes No 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 No Applicant(s) Questionnaire1. 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 No 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 No 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 No 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 AA NA Anger Management Group Therapy Cultural Activities Other Is the Applicant on the Methadone Program? Yes No 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 PersonsInclude Name, Relationship & Contact Information for each individual Health Information1. 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 explain3. Does the Applicant(s) carry an Epi-pen for allergies? Yes No 4. Is the Applicant(s) currently in any type of treatment or counselling for emotional or mental health problems? Yes No If yes, where? 5. Please add any additional information that will assist our understanding of the Applicants' needs. Brantford Native HousingConsent 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
