Spirit Way Second Stage Transitional Housing Program Application Form Phone Number: 604 873 2217 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 1 2 3 4 5 6 7 8 9 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? * Yes No Indigenous Status Number Are you Connected with Them? Yes No Band / Nation Would you like to Reconnect? Yes No 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 * Next 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? * Yes No Please complete the info about your children below * Name * Age * Gender * In your care? * Yes No × Add new Is there anything we need to know about your children? (ie: medical, allergies, medication, behaviour concerns, etc.) Next 3) History of abuse: Please select which forms of abuse apply to you * Physical Sexual Spiritual Emotional Psychological Verbal Financial Other How long have you been in an abusive situation/relationship? Describe the last incident that brought you to fill this application * Do you have a restraining order? * Yes No Please explain Have the children witnessed or experienced any kind of abuse? * Yes No Please explain what happened Please describe your CURRENT relationship with the abuser * Abuser Information Name of abuser Will the abuser look for you? Yes No Age Height Hair Color Eye color Ethnicity Distinguishing Marks: (ie: tattoos, scars, birthmarks, etc.) Last know address Place of Work Vehicle Color Police record? Yes No Please Describe Drug or Alcohol Issues Yes No Access to weapons Yes No Legal/Police Involvement (ie: protection order, court proceedings, custody arrangements or visitation arrangements we need to know about?) Next 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? Yes No 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? Yes No 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? Yes No Please describe your children health issues Are you and/or your children prescribed any medications? Yes No Please fill the info about medications Name Medication Reason × Add new Do you and/or your children struggle with substance use of any kind? Yes No 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? Yes No Please explain Have you thought about or attempted to take your life recently or in the past? Yes No Please explain about How do you feel we can better support you and/or your children, if possible? Next 5) Education and Work Experience: Have you completed your Grade 12? Yes No Have you taken any training, college or university courses? Yes No Please describe Do you plan to go to school, training, college or university in the near future? Yes No Please describe Would you like support with going back to school? Yes No Are you currently employed? Yes No Please explain Do you plan to go back to work? Yes No Please explain Would you like support to go back to work? Yes No Have you contacted any agencies to support you with either going back to school and/or work? Yes No Please list Agency name × Add new Next 6) Housing When was the last time you had stable housing? Have you previously stayed at any other transitional housing programs? Yes No Please describe when and where Are you comfortable with us contacting them for a reference? Yes No Have you applied for housing? Yes No Please list when and where Are you connected with other services, agencies, or supports to assist you with housing? Yes No Please list below Do you have your own furnishing? Yes No Would you be able to find a place to store them as there are no outside furnishings permitted at Spirit Way? Yes No Next 7) Financial Information Do you have a source of income? Yes No Please describe from where What is your monthly income? Please select any income you are receiving Income assistance child support disability child tax benefit employment insurance Do you have an account solely in your name only? Yes No Do you need any support with applying for income assistance, child support or filing your taxes? Yes No Please describe Next 8) Support and Services Needed Do you have any friends, relatives or a network in place which is supporting you? Yes No 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.? Yes No Are there any other ways that would be helpful in supporting you and your children during your program participation here at Spirit Way? Next 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? Yes No 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? Yes No 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? Yes No Are you comfortable with confidentiality during and after your program participation here at Spirit Way? Yes No Submit
