Mint Communities Housing Application

Housing Application
Submitting Application for the Following Housing Site:
Do you have medication/health needs?
Do you have social support needs?

APPLICANT INFORMATION
Date*

MonthDay Year
Date
Full Name*

First Name Last Name
Gender*

MFOther (Comments are optional)
Date of Birth*

MonthDay Year
Date
Current Address*

Street Address

Street Address Line 2

City Province

Postal Code Country
Phone Number
Alternate Phone Number (if available)
Emergency Contact Name/Relationship/Phone Number*
Languages Spoken

REFERRING SOURCE INFORMATION

2. REFERRING SOURCE INFORMATION:

	Name	Contact Number
Referral Agency
Primary Mental Health Worker
Psychiatrist
Physician
Guardian
Trustee
Family Contact

REASON FOR REFERRAL/APPLICATION
3. REASON FOR REFERRAL/APPLICATION

Facing EvictionReady for DischargeHomelessSubstandard LivingLeaving Abusive RelationshipOther
Date of Discharge (if applicable)

MonthDay Year
Date

HOUSING HISTORY
4. Housing History*

IndependentGroup HomeAssisted LivingHomeless
Please provide detailed information on housing history*
Current Landlord's Name

First Name Last Name
Current Landlord's Phone Number
Please enter a valid phone number.
Previous Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Previous Landlord's Name

First Name Last Name
Previous Landlord's Contact Information
Please enter a valid phone number.
Are you likely to become homeless in the next month?

YesNo
If yes to the previous question, please explain
Do you have a pet(s)?*
Please specify what pet(s) you have

SOURCE OF INCOME
5. Source of Income:*

CPPIncome SupportsAISHOther
Amount of Income*
Name of Income Support/Case Worker*

First Name Last Name
Phone Number*

MENTAL HEALTH HISTORY
6. MENTAL HEALTH EVALUATION: – please elaborate on diagnosis, symptoms, and behaviors related to mental health
Mental Health Diagnosis*
Other Mental Health Diagnosis
Please include any relevant histories/assessments (if applicable)
Check off all that apply

FASDBrain InjuryLearning DisabilityPDD (Persons with Developmental Disabilities)
Details (if applicable)

SELF-HARM, SUICIDAL, AND/OR AGGRESSIVE BEHAVIOURS
7. DESCRIBE ANY SELF-HARM, SUICIDAL, AND/OR AGGRESSIVE BEHAVIOURS
Intentional Self-Harm
Suicidal Ideation/Attempts
Aggressive Behavior (Verbal or Physical)

MEDICATION HISTORY
8. MEDICATIONS: – please include dosage and frequency, or attach a current medication report
Please check off all which apply to you*

I take my medications as prescribed.I have medications prescribed to me, but I choose not take them.I have medications prescribed to me, but I have misplaced them or forget them.I have medications prescribed to me, but I have not filled the prescription.I have medications prescribed to me, but I sell/trade them.I do not have any medications prescribed to me.

Medication History

	Medication Name	Dosage, Frequency, Additional Info
1
2
3
4

Attach Photos of Medication List / Information

PHYSICAL/MEDICAL HISTORY
9. PHYSICAL/MEDICAL CONSIDERATIONS

DiabetesCardiovascularCOPDMobility IssuesOxygen UseTransfer AssistanceOther
Details for Previous Question (if necessary)

Allergies/Intolerance

	Substance Allergic/Intolerant To	Reaction
1
2
3
4
5

SUBSTANCE USE HISTORY
10. PRESENT SUBSTANCE USE PATTERN: – attach any assessments related to substance use to this referral form

Substance Use History

	Substance	How Often Per Week/Month/Year	Amount Per Occasion
1
2
3
4

Substance Use Details
Date of Last Use

MonthDay Year
Date
Do you currently use tobacco products? (e.g. cigarettes, cigars, etc.)*

LEGAL INVOLVEMENT
11. Do you currently have any legal involvement? If so please explain
Do you currently have any gang affiliation?*

YesNo

OTHER COMMUNITY AGENCIES/SUPPORTS CURRENTLY INVOLVED

12. OTHER COMMUNITY AGENCIES/SUPPORTS CURRENTLY INVOLVED:

	Name	Agency, if applicable	Phone Number
1
2
3

CONSENT TO DISCLOSE HEALTH INFORMATION
Consent to Disclose Health Information
Please take into consideration that Mint Communities housing initiative is designed to provide homes with a supportive health component to individuals with complex health needs that require housing.

The patient/client or his/her authorized representative must complete this form before Mint Communities Betterment Agency may disclose the patient’s/client’s health information to someone else (unless Alberta’s Health Information Act authorizes disclosure without consent). The information on this form, together with any record authorizing a representative to act on behalf of the patient/client, is being collected under part 3 of the Health Information Act for the purpose of recording the patient’s/client’s consent to the specified disclosure and will be filed on the patient/client record. For questions about this collection of information, contact the program area that provided you this form or contact the Chief Privacy Officer at 10301 Southport Lane SW, Calgary, AB T2W 1S7 or call 1.877.476.9874.

Details of health information being disclosed:

Diagnosis, symptoms, symptom management, relevant psychiatric and social history, assessment results, medications, support/clinicians involves in the client’s recovery, program participation, recovery and discharge planning.

Name of individual(s)/organization(s) information is being disclosed to (select the corresponding program which is being applied to)

Mint Health + Drugs

Purpose(s) of disclosure:
For intake/assessment for a housing program and, if accepted, ongoing support/treatment within the indicated program. For evaluation purposes to determine the effectiveness of Mint Health + Drugs. Information will be kept anonymous and confidential. We will only show information on groups, not individuals. You can cancel your consent to participate in the research at any time by talking with an Mint Health + Drugs staff member.
Authority of Person(s) Giving Consent (If Not the Applicant)

Guardian (or Trustee) - of a minor under the age of 18 years, who is not determined to be a mature minor - named in a Guardianship Order/appointed under the Adult Guardianship and Trusteeship Act, if access to health information relates to the powers and duties of the guardian (or trustee)Nearest relative under Mental Health Act - if access to health information is necessary to carry out obligations of the nearest relativeAgent - appointed in an enacted personal directive according to the Personal Directives ActPersonal representative - of a deceased patient, if the access to information relates to administration of the individual’s estatePower of attorney - if access to health information relates to the powers and duties of the attorneyWritten authorization - any written authorization from the individual to act on the individual’s behalfSpecific decision maker - as defined in the Adult Guardianship and Trusteeship Act
Applicant Signature*

Clear
Date*

MonthDay Year
Date
Name of person giving consent

First Name Last Name
Ideal Move-in Date If Accepted (Note: This date is subject to approval by Mint Communities/Landlord)

MonthDay Year
Date

APPLICATION FOR LEASE - GREYSTONE RESIDENTIAL MANAGEMENT CORP.
Application for Lease - Greystone Residential Management Corp.

I understand that Mint Communities operates a housing program within Britannia Crossing - 15809 102 Avenue, Edmonton, Alberta, which is managed by an external property management company, Greystone Residential Management Corp.

The purpose of this arrangement is to ensure residents can receive a timely response on any building repairs and maintenance requests, and that the amenities within the building will be kept to a high standard to offer an optimal living experience.

The information and consents provided below are for the purpose of meeting Greystone Residential Management Corp.'s needs as part of their administrative process.

Mint Communities will also need to share demographic information, including but not limited to your:
- Full Name
- Date of Birth
- Phone Number
- Present Address
- Previous Address
- Employer/Source of Income
- Emergency Contact
- Smoking History
___________________________________________________________________
I/We, the undersigned, herein also known as the Applicant(s), hereby agree to offer to rent residential premises known as:

{submittingApplication} AT A MONTHLY RENT OF ${damageDepositrent}.

I understand this offer is subject to the acceptance by the Landlord/Landlord’s Authorized agent. If this offer is not accepted, any deposits paid shall be refunded. If the Applicant(s) fails to enter, or proceed with, the Lease Agreement after the offer is accepted, the Applicant will be held liable for payment of the equivalent of one month’s rent to the Landlord and any deposits paid may be used as partial or full payment towards such amount.

Consents

The applicant hereby consents to the Landlord obtaining credit, personal and employment information on the Applicant(s) from one or more consumer reporting agencies and from other such sources of such information. The Applicant(s) authorizes the reporting agencies and any other person, including personnel from any government ministry or agency, to discuss relevant information about the Applicant(s) to the Landlord. If this application is accepted, the Applicant(s) understands that the above information will also be used and disclosed for responding to emergencies, ensuring the orderly management of the tenancy including collection of any outstanding amounts when tenancy ends and complying with legal requirements.

The Applicant(s) agrees to carry sufficient insurance to cover his property against loss or damage from any cause and for third Initials party liability and the Applicant(s) agrees that the Landlord will not be responsible for any loss or damage to the Applicant’s property.
Damage Deposit/Rent
Signature *

Clear
Send a Copy of Application Response To:
example@example.com

SUBMIT
Should be Empty:

Housing Application

Consent to Disclose Health Information