Please indicate which program location you are in interested in applying for
Applicant
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First Name
Last Name
Date of Birth
*
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Age
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Marital Status
*
First Name
Last Name
Date of Birth
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Marital Status
Referred From
Preferred Language
Contact
Comments
Previous Accommodation?
*
If other, please specify
Client Type?
*
If other, please specify
Identifying Gender
*
If other, please specify
Current Address
City
Postal Code
Email Address
Contact Number
Alternate Contact #
May a message be left for you at these numbers?
Name
First Name
Last Name
Address
Phone
(###)
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Do you have children in your care?
If yes, how many?
Children
Please Include Name, Age, Date of Birth, and Gender For All Children Seperated by This Format: John Doe, 10, 22/08/2014, male ; Sarah Smith, 4, 11/02/2020, female;
Are you currently pregnant?
If yes, when is your due date?
MM
DD
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Are you currently involved in any community agencies?
If so, which agencies?
Do you have any health concerns?
If so, please explain
Do you have any addictions?
If yes, please indicate what (alcohol, drugs, gambling, etc.) and give details (frequency of use, clean time, etc.)
Are you interested in treatment of any kind or have you attended any treatment?
If yes, please give details (when, where, etc.)
Do you agree to abstain from using alcohol or illicit drugs while in this program?
Have you ever been to see a Psychiatrist/Psychologist?
Name of Psychiatrist
First Name
Last Name
Address
Phone
Country
(###)
###
####
Fax Number
Is there ongoing care?
Psychiatric Diagnosis
What do you know about the YW Transitional Housing Program?
What expectations do you have from me personally as your Transitional Housing Support Worker/Case Worker?
What behaviours or lifestyle habits do you currently engage in that you believe enhances you?
What behaviours or lifestyle habits do you currently engage in that you believe are self-destructive?
What barriers do you foresee in making lifestyle changes?
Income
Please specify the Source, Amount, and Frequency by listing using this format: Earnings, $1450, bi-weekly ; Support Payments, $830, monthly ;
Are you eligible for Niagara Regional Housing?
If not, please explain why?
Do you give the YWCA Niagara Region permission to verify that you are active on the general waitlist with Niagara Regional Housing?
Do you owe any funds to Niagara Regional Housing?
If yes, please explain why?
Employment: Are you currently working? If so where do you work? If no, who was your last employer?
How many hours do you work in a week?
Why do you think you could benefit from living in supportive housing?
Is there anything else we should know about you that will help us assess your suitability for the program and help us to serve you better if you are accepted?
Provide a list of your housing placements for the last year (please include dates).
What caused you to leave your previous living arrangement?
How long have you been living in your current living arrangement?
Please list the barriers to permanent housing that you have encountered.
How much are you able to pay for rent per month?
Ground Floor
1
2
3
Basement
1
2
3
Upstairs
1
2
3
Are you able to climb stairs?
Do you smoke cigarettes?
Do you have a registered service animal with appropriate paperwork?
Please note that only service animals are permitted in our programs. Non-service animals will not be accepted. Thank you for your understanding.
If so, please list
Please list three short-term goals and three long term goals that you would like to achieve
Short Term
What skills do you need or want to develop? Please check off as many that are applicable to you.
Budgeting
Relationship / Life Skills
Parenting
Education / Training
Anger Management
Self- Esteem
Any other skills you would like to explore?
Would you like to be involved in any support groups offered by the YWCA
Sex Trade On My Terms (STOMT)
Drop in programs in St. Catharines & Niagara Falls.
STOMT is a weekly drop-in for women-identified individuals who engaged in survival sex work. We offer sex positive, non-judgmental support in an inclusive, safe space. Participants can come hang out and grab a meal, access community referrals and resources, clothing donations and harm reduction supplies, or just drop by for a chat.
Women’s Addiction Recovery Mediation (WARM)
Virtual groups Monday & Wednesday.
WARM provides Personal Support Recovery Programs designed for women experiencing addiction and families affected by addiction. Professionally facilitated, participants are guided through a process group that provides the opportunity to share experiences with addiction in a safe, confidential and mutually respected environment. Participants are then invited to consider a psycho-educational skills development activity that builds motivation, awareness, coping skills and a balanced life of wellness.
Are you willing to sign a participation agreement with the YWCA? (You can revoke the relationship at any time; however, this action will result in your immediate discharge from the program.)
City Selection
Applicant Name
First Name
Last Name
Date
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I
First Name
Last Name
Name
(Participant)
First Name
Last Name
Date Signed
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Name
(Service Provider)
First Name
Last Name
Date Signed
MM
DD
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Please list in the following format : Name of Dependent, Date of Birth of Dependent; Name of Dependent, Date of Birth of Dependent; Name of Dependent, Date of Birth of Dependent
Name
First Name
Last Name
Date
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Name
First Name
Last Name
Date
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