Applicant Name
*
First Name
Last Name
Date of Birth
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Age
Marital Status
Referred From
Preferred Language
Contact
Comments
Please indicate your previous accommodations
If other, please specify...
Client Type
If other, please specify...
Identifying Gender
If other, please specify...
Pronouns
Current Address
City
Postal Code
Email
Contact Number
(###)
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####
Alternate Contact #
(###)
###
####
May a message be left for you at these numbers?
Name
First Name
Last Name
Street Address
City
Phone Number
(###)
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Are you currently involved with any community agencies?
If so, which agencies?
Do you currently have health concerns?
If so, please explain...
How would you describe your current state of health?
Do you have addictions?
(Alcohol, Drugs, Gambling, etc.)
If so, what?
Does/has your addiction impacted your ability to maintain housing?
If so, are you willing to participate in harm reduction model?
What do you know about the Court St Transitional Housing Program?
What are your expectations of the Court St Transitional Housing Program?
What long term expectations do you have from working with a Transitional Support Worker?
What barriers do you foresee in making lifestyle changes?
Do you have a support network? If so who?
Income (e.g. OW, ODSP, earnings, support payments, pension, etc.) - you must disclose all income sources and amounts.
Please specify the Source, Amount, and Frequency by listing using this format: Earnings, $1450, bi-weekly ; Support Payments, $830, monthly ;
OW/ODSP Case Manager:
Phone
(###)
###
####
Email
Do you have any monthly payments for outstanding debts of other obligations?
If yes, please show amounts and explain...
How many hours do you work in a week?
List any major stressors in your life right now
Why do you think you could benefit from living in supportive housing?
What caused you to leave your previous address?
How long have you been living in your current housing?
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?
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.
Please list three short-term goals that you would like to achieve
Please list three long-term goals that you would like to achieve
What skills do you need or want to develop? Please check off as many that are applicable to you.
Any others?
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.)
Name
First Name
Last Name
Date
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DD
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