APPLICATION FORM FOR YOUTH SERVICES

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1 APPLICATION FORM FOR YOUTH SERVICES Home Base Housing s Youth Services program provides supportive housing for young men or women who require supports. If you live in our housing, a Case Manager will be assigned to you. If you are interested in our housing, you must now complete this application form and return it to us. Let us know if you need help with any part of the application. Once we receive the application form, a Case Manager will review your application to deem eligibility for the Youth Services program. Following this process, you will be contacted as to whether you meet our requirements for supportive housing or not. If you do, a time will be set up to complete a full assessment and to determine your level of support needed. Once the full assessment is complete, you be put on a wait list for a vacancy that is best suited to meet your needs. The time on the wait list may vary based on your situation and the availability of our housing. Return the attached form to: ATTN: Youth Services, Home Base Housing, 540 Montreal St, Kingston, K7K 3J2 or fax to You may also download the form to your computer and to If your contact information changes please let us know by calling Home Base Housing 417 Bagot Street Kingston, ON K7K 3C1 tel: (613) fax: (613) Youth Services 417 Bagot Street Kingston, ON K7K 3C1 tel: (613) fax: (613) Supportive Housing Program 417 Bagot Street Kingston, ON K7K 3C1 tel: (613) fax: (613) Housing Help Centre 426 Barrie Street Kingston, ON K7K 3T9 tel: (613) fax: (613) In From The Cold Shelter 426 Barrie Street Kingston, ON K7K 3T9 tel: (613) fax: (613) A United Way member agency

2 Home Base Housing YOUTH SERVICES application I am applying for : Adult Housing (20 and older) OR Youth Services (ages 16-24) Applicant Name: Date of application: Social Insurance Number (SIN) Date of Birth (d/m/yr) Language Spoken Sex: Male Female Citizenship: Transgendered Do you have a permanent address that you currently live at? NO YES If yes: complete below: Current Address: Unit: City: P.C. Telephone#: Other telephone: When did you move into this address? Month Year If no: What is the best way to reach you? Telephone: Do you have a secondary contact? (Family member, friend, school, agency) Name: Relationship: Phone: When did you move into this address? Month Year It is important that you notify us if your contact information has changed. If you do not have a permanent address: Please describe your current living arrangement. For example, are you living in a rooming house or are you staying with friends or family? Are you leaving the hospital or jail? Are you staying at a shelter or on the street? 2

3 Home Base Housing - YOUTH SERVICES application.. continued How long have you been living without a permanent address? 0-1 yr 1-4 yrs 4yrs+ In the past three years, how many times have you been homeless and then housed? 0-2 times 2-4 times 4+ times Housing Choice I want (choose one) : Either shared or 1 bedroom Shared housing only 1-bedroom only I need a wheelchair accessible unit: NO YES Other preferences? General Information: 1. What is/are your source(s) of income? 2. What is your gross monthly income? / month from all sources 3. Home Base Housing is geared towards single adults. Do you plan on living alone if you move in (choose one)? YES NO NOT SURE 4. If housed, would you work regularly with a Case Manager? YES NO NOT SURE Support Needs: The following questions help us understand what the level and types of support you might need. Please answer honestly. Persons with higher needs are considered for our supportive housing first. 1. Have you dealt with police, a crisis service or been to emergency in the past 3 months? YES NO If yes, how many times in the last 3 months (circle one)? 3

4 1-4 times 5-10 times more than Have you assaulted someone or been assaulted in the last year? YES NO 3. Do you have any legal issues going on right now? YES NO If yes, please explain: 4. Are you involved in any risky behavior, like running drugs, having unprotected sex, exchanging sex for money or drugs, sharing needles? YES NO 5. Where are you sleeping most often? Shelters Streets Vehicle Waterfront Other (Please specify below) 6. Do you make enough money to get by each month? YES NO 7. Do you do things during the day that you enjoy? YES NO 8. Are there people in your life that take advantage of you or that you spend time with but don t enjoy their company? YES NO 9. Where do you go for health care? Hospital Clinic Street Health Family Doctor Other Do not go 10. Do you have any chronic health issues? YES NO 4

5 If yes, describe: 11. Do you or have you had any medications prescribed to you that you do not take, sell, have misplaced or haven t had the prescription filled? YES NO 12. Have you experienced any trauma or abuse in your past that you think has resulted or contributed to you being homeless? YES NO 13. Have you: Ever had an addiction to drugs or alcohol, or been told you do? YES NO Used drugs or alcohol every day for the past month? YES NO Used injection drugs in the past six months? YES NO Ever been treated for alcohol abuse and returned to drinking? YES NO Drank anything like cough syrup, mouthwash, rubbing alcohol? YES NO Blacked out after using drugs or alcohol? YES NO Ever gone or been taken to hospital about a mental health concern? YES NO Had a serious brain injury or head trauma? YES NO Talked to a psychiatrist or professional about your mental health? YES NO Ever been told you have a learning or other disability? YES NO Are you or have you ever been in the care of a Children s Aid Society? YES NO b) If YES, would you be willing to work with a Youth In Transition Worker? (For youth in care or youth who were in care). YES NO c) If YES, Please sign below, which will allow Home Base Housing to share your information with the YITW who will be in contact with you. 5

6 I, give consent to Home Base Housing to share my contact information with the Youth In Transition Worker through K3C. Preferred method of contact: Phone Text only: Social Housing Registry In order to live at Home Base Housing, applicants must qualify for Rent-Geared-To Income (RGI) Housing. This is done through the Social Housing Registry. Have you qualified for RGI Housing? YES NO NOT SURE If you are not sure, may we have your permission to contact the Social Housing Registry to find out your status? YES NO Other supports and consents: As part of the application process, we may need to speak with other people who know you. Please list names and contact numbers of other persons. Ideally, these are workers in agencies who have had recent contact with you. 1 Name Title Agency Contact Tel (if known) I give my consent to share information with the above person related to my application for supportive housing. Signature: Date 2 Name Title Agency Contact Tel (if 6

7 known) I give my consent to share information with the above person related to my application for supportive housing. Signature: Date 3 Name Title Agency Contact Tel (if known) I give my consent to share information with the above person related to my application for supportive housing. Signature: Date IMPORTANT: If you are assisting the applicant with this referral, please include your information in the chart above so we have permission to contact you. Other Comments to Support My Application: Applicant s Name: (Print): Signature: Date: 7

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