432 Springbank Ave. N #20. Woodstock. ON. N4T 1N7 Phone: Fax: TRANSITIONAL HOUSING APPLICATION FORM WELCOME!

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1 432 Springbank Ave. N #20. Woodstock. ON. N4T 1N7 Phone: Fax: TRANSITIONAL HOUSING APPLICATION FORM WELCOME! Ingamo Homes is Second Stage Housing for women with or without children who are survivors of violence. With this application you can be considered for transitional supports and housing with Ingamo Homes. The purpose of the questions is to help us learn more about you and assess what your particular needs are, so please answer them completely and accurately. It is our preference for you and this process that this form be completed with an ending violence against women worker. Having this assistance can support you in many ways, including immediate safety planning, support, options, resources and referrals. The completed and signed form should be faxed or mailed to the above address. You do not need to send this information sheet with your application. Your application will be processed efficiently, respectfully and in confidence. The application interview will be arranged with you in the near future, so please ensure we have accurate contact information. As the interview includes adult discussions regarding abuse, you will need to make childcare arrangements. For this meeting please bring the following: Birth certificate for all persons who may be residing in the program Income verification Full name, address and phone # of emergency contacts (2) PLEASE RETAIN THIS SHEET FOR YOUR OWN REFERENCE. 1

2 INGAMO STAFF USE ONLY: Interview Date: WISH # A. PERSONAL INFORMATION: 1. Full Name: 2. Alternate Name(s DOB (dd/mm/yy) / / 3. Current Address 4. Current Telephone Number Safe to leave message? Y / N Cell number Safe to leave message? Y / N address Safe to send message? Y / N 5. Safe Alternate Contact Name and Number Relationship/Agency 6. Vehicle information: Make: Model: Year: Colour: License Plate: Driver s License: 7. Preferred language Do you require cultural interpretation for the interview? Y / N If Yes, which language? Country of Origin: 8. Physical Description: Please fill in/circle the most appropriate description. Weight Height Build Eye Colour Hair Colour Hair Length Hair Style Complexion Tattoos/Piercings Distinguishing Features Eyewear Teeth Native/Aboriginal Extra-Large, Large, Medium, Petite, Small Blue, Blue-Brown, Brown-Hazel, Dark Brown, Green, Hazel, Hazel-Blue, Other Auburn, Black, Blonde, Brown, Dark Brown, Grey, Light Brown, Red, Salt and Pepper, Other Long, Medium, Short, Shoulder length, Shaved, Bald Afro, Braid, Bushy, Curly, Dreadlocks, Layered, One length, Short, Shaved, Straight, Wavy Brown, Dark, Fair, Light, Medium Glasses, Contacts No, Non-Status Aboriginal, Status, Unknown 2

3 9. Health information: Health card Family Doctor Location Dentist Location Other Doctor Location Medication Reason Prescribed Any special health situations, allergies or limitations we should be aware of? Y / N If yes, please explain: 10. Counselling/Support/Advocacy Services Agency Worker Reason 11. Status in Canada Canadian Citizen Landed Immigrant Refugee Claimant 12. How did you find out about Ingamo Homes? Shelter Staff Community Support Worker Healthcare Professional Friend Website Brochure Other (please list ) B. CURRENT HOUSING SITUATION 1. Are you currently homeless? Y / N 2. Where are you staying now? Family / Friend Abused Women s Shelter Motel Hospital Owned Residence Rented Residence Homeless Shelter Correctional Facility Other 3. If you are applying from a shelter, what date did you enter? (dd /mm/yy) / / 4. If you are not applying from a shelter, what date did you leave the abuser?(dd/mm/yy) / / 5. Have you applied for subsidized housing through Oxford Social Housing or other communities? Y / N If yes, what status have you received? Abuse Priority Homeless Urgent Needs Chronological Don t Know 3

4 C. CHILDREN S INFORMATION 1. Please provide the following information for any children living with you: Name M / F DOB Health card Medical/allergies 2. Please provide the following information for children not living with you: Name M / F DOB Health card Medical/Allergies 3. Who has custody presently? 4. What are the arrangements? 5. Has there ever been threats to take the child (ren)? Y / N By whom: 6. Are you involved with CAS? Y / N Date involvement began Worker s Name: Number and Ext 7. Do you have any upcoming Court Dates regarding custody, access or CAS? Y / N Date: Explain: 8. Counselling/Support/Advocacy Services for Children: Child s Name Agency Worker Reason 9. Other Child related information we should be aware of: 4

5 D. INFORMATION REGARDING THE ABUSER 1. Full Name: 2. Alternate Names 3. Date of Birth (dd/mm/yy) : / / 4. Present Address: 5. Home Number: Cell Number : 6. Vehicle Information: Make: Model: Year: Colour: License Plate: Driver s License: 7. Is the abuser currently employed: Y / N List present or last place of employment: Occupation: Employer: 8. Relationship to you: married common-law boyfriend other 9. Length of your relationship: 10. Physical description: Please fill in/circle the most appropriate description Weight Height Build Extra-Large Large Medium Petite Small Eye Colour Blue, Brown, Brown-Hazel, Dark Brown, Green, Hazel, Hazel-Blue, Unknown Hair Colour Auburn, Black, Blonde, Brown, Dark Brown, Grey, Light Brown, Red, Salt and Pepper, Other, Unknown Hair Length Bald, Long, Medium, Receding, Short, Shoulder Length, Shaved, Unknown Hair Style Afro, Braid, Bushy, Curly, Dread locks, Layered, One Length, Short, Shaved, Straight, Wavy, Unknown Complexion Brown, Dark, Fair, Light, Medium, Unknown Facial Hair Tattoos/Piercings Distinguishing Features Native/Aboriginal No Non-Status Aboriginal Status Unknown 11. Can you provide a picture? Y / N 12. Does this person have access to guns or weapons? Y / N 5

6 13. Has this person ever threatened to kill you, your children or others? Y / N If yes, please explain: 14. Does this person use drugs or alcohol? Y / N 15. Is there any other way in which this person(s) is a danger to you and/or your children or others? 16. Have you ever needed to seek medical attention regarding the impact of the abuse? Y / N If yes, please explain 17. Have police laid charges against the abuser? Y / N If yes, please describe 18. Has there been any police or court involvement? Y / N If yes, when and how many times? 19. Please list and explain any upcoming court date: 20. Do you have any of the following orders in place? Peace Bond Restraining Order Custody 21. If police were involved, was the police intervention helpful to you? Y / N 22. Are you aware of any past criminal records / charges against the abuser? Y / N What were they: 23. Is there anything else you would like us to know about the abuser(s)? 6

7 E. TYPES OF ABUSE 1. Have you experienced any of the following? Please check all that apply and explain: Form of Abuse (examples) Once Some Lots Comment/Examples Isolation: (restricting your freedoms, keeping you away from family, friends, etc) Male Privilege (treating you like a servant, demanding you obey, treating you like an inferior) Threats & Psychological (threatening, harassment, stalking, depriving you of sleep or food, turning people against you, destruction of personal items) Economic (withholding money or necessities, restricting you to an allowance, building up debts, making you account for your money, making you turn over earnings) Intimidation (sudden mood changes, shouting, hitting or throwing things, killed or neglected animals/pets, giving you the silent treatment)to hurt you, assaulted you when you were Emotional (insults, criticism, blaming, undermining your parenting, calling you names, putting you/appearance down) Sexual (unwanted kissing or touching, withholding affection, excessively jealous, did not allow birth control, use of sex as a punishment, sex accompanied by violence or threats, pressured or forced sex) Physical (threw you, punched you, bit you, shook you, pulled your hair, choked you, covered your mouth, threatened you with a weapon or used a weapon to hurt you, assaulted you when you were pregnant) Spiritual ( stopped you from practicing or participating in spiritual exploration/ fulfillment, made fun of your convictions) 7

8 2. Did you experience abuse not mentioned here? If so, please explain: _ F. INCOME INFORMATION 1. Income Source Source Monthly Amount Ontario Works (OW) Ontario Disability Support Program (ODSP) Canada Pension (CPP) Disability Employment Insurance (EI) Salary / Wages Insurance Pension Other Total Monthly Income Comments/Additional Information: G. NEEDS 1. What kind of supports do you feel you need? Please check all that apply: Legal Housing Financial Counselling / Support / Advocacy Medical Parenting Safety Planning Community Resources Other 2. Please tell us how living at a second stage shelter would be of benefit to you and/or your children: 3. If someone assisted you in filling out this application form, please state their name and agency or relationship to you: Name: Relationship/Agency: 8

9 DECLARATION This is your agreement with us. Your confidentiality will be respected. Please read carefully before signing. I have done my best to ensure that the information provided in this application is correct. Applicant Signature Date: FAX COMPLETED APPLICATION TO OR MAIL TO: Ingamo Homes 432 Springbank Ave N., #20, Woodstock ON N4T 1N7 9