Spirit Way Second Stage Transitional Housing Program Application Form

Fax: 604-873-2296
EMAIL: sw_program_manager@hsls.ca

Please ensure the form is COMPLETED IN FULL before submitting to avoid delays in the application process

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Last Page
Date Application Submitted *
1) Personal Information:
Name
Marital Status
Birthdate
Age
Current Address
Last Address
Email
Phone Number
Safe Message Number
Nationality
Identify as Indigenous?
Indigenous Status Number
Are you Connected with Them?
Band / Nation
Would you like to Reconnect?
Referred by
Phone number
Social Worker's Name
Social Worker's Agency
Social Worker's Phone Number
Emergency Contact Name
Emergency Contact Number
Relationship to Emergency Contact
2) Children's Information:

 Disclaimer-Obligation to Report to MCFD: Helping Spirit Lodge Society is responsible to secure the safety of all minors, in and out of care, and will report any circumstances where the child’s wellbeing is at risk of harm. 

Do you have children?
Please complete the info about your children below
Is there anything we need to know about your children? (ie: medical, allergies, medication, behaviour concerns, etc.)
3) History of abuse:
Please select which forms of abuse apply to you
How long have you been in an abusive situation/relationship?
Describe the last incident that brought you to filling this application
Do you have a restraining order?
Please explain
Have the children witnessed or experienced any kind of abuse?
Please explain what happened
Please describe your CURRENT relationship with the abuser *
Abuser Information
Name of abuser
Will the abuser look for you?
Age
Height
Hair Color
Eye color
Ethnicity
Distinguishing Marks: (ie: tattoos, scars, birthmarks, etc.)
Last know address
Place of Work
Vehicle
Color
Police record?
Please Describe
Drug or Alcohol Issues
Access to weapons
Legal/Police Involvement (ie: protection order, court proceedings, custody arrangements or visitation arrangements we need to know about?)
4) Medical Information:
Doctor's name
Doctor's phone
Do you have any physical health issues/concerns that we need to know about so that we can better support you, if possible?
Please describe your physical health issues
Do you have any mental health issues/concerns that we need to know about so that we can better support you, if possible?
Please describe your mental health issues
Do your children have any physical health or mental health issues/concerns that we need to know about so that we can better support them, if possible?
Please describe your children health issues
Are you and/or your children prescribed any medications?
Please fill the info about medications
Do you and/or your children struggle with substance use of any kind?
Please explain
Are you comfortable with living in a substance free (of any kind) environment?
Have you thought about harming yourself and/or others recently or in the past?
Please explain
Have you thought about or attempted to take your life recently or in the past?
Please explain about
How do you feel we can better support you and/or your children, if possible?
5) Education and Work Experience:
Have you completed your Grade 12?
Have you taken any training, college or university courses?
Please describe
Do you plan to go to school, training, college or university in the near future?
Please describe
Would you like support with going back to school?
Are you currently employed?
Please explain
Do you plan to go back to work?
Please explain
Would you like support to go back to work? 
Have you contacted any agencies to support you with either going back to school and/or work? 
Please list
6) Housing
When was the last time you had stable housing?
Have you previously stayed at any other transitional housing programs?
Please describe when and where
Are you comfortable with us contacting them for a reference?
Have you applied for housing?
Please list when and where
Are you connected with other services, agencies, or supports to assist you with housing?
Please list below
Do you have your own furnishing?
Would you be able to find a place to store them as there are no outside furnishings permitted at Spirit Way?
7) Financial Information
Do you have a source of income?
Please describe from where
What is your monthly income?
Please select any income you are receiving
Do you have an account solely in your name only?
Do you need any support with applying for income assistance, child support or filing your taxes?
Please describe
8) Support and Services Needed
Do you have any friends, relatives or a network in place which is supporting you?
Please describe
Are you comfortable with the Spirit Way Team supporting you in your healing journey with Indigenous Cultural Teachings, Ceremonies, Talking Circles and Time with Elders and Knowledge Keepers, etc.?
Are there any other ways that would be helpful in supporting you and your children during your program participation here at Spirit Way?
9) Program Clarity
Are you comfortable with living in a community setting where you will be working alongside other women and the Spirit Way Staff to assist you in your healing journey?
Are you aware that you are applying for a second-stage transitional housing program which will assist you in your healing and move forward to becoming an independent and empowered woman and/or mother in the community?
Are you also aware that you will be required to follow our organization’s policies and guidelines during your program participation here at Spirit Way?
Are you comfortable with confidentiality during and after your program participation here at Spirit Way?