Brantford Native Housing Transitional Housing Program

Brantford Native Housing Transitional Housing Program

Application Package
BNH Office Address

318 Colborne Street EastBrantford, ONN3S 3M9Phone: (519) 756-2205 x 227 or x 224, Fax: (519) 756-1764
APPLICATION INFORMATION

A.   Background

Brantford Native Housing operates multiple transitional housing facilities. The many different housing facilities are geared to various Indigenous households. Our transitional housing program is offered to the following Indigenous households who are experiencing homelessness or are at-risk of homelessness:

1. Single males aged 18+

2. Single females aged 18+

3.    Families

Clients eligible for Brantford Native Housing’s transitional housing programming are only permitted to stay in the transitional facilities for a duration of up to 12 months (1 year).

Please note, BNH’s transitional housing program is not a shelter and is not intended to provide emergency housing in any way. Residents will be expected to participate in programming to support household development and wellbeing. Further, it is a requirement of the transitional housing program to maintain abstinence from all alcohol and recreational (mood altering) drugs while residing in BNH’s housing facilities.

Completed Applications can be submitted via this form or printed off an brought in to our main office.

Mail or Drop Box – 318 Colborne St E, Brantford ON, N3S 3M9

Faxed – 519-756-1764

Once we receive and review completed prospective client application forms, one of Brantford Native Housing’s staff will reach out and connect with the applicant and schedule an intake interview.

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B.   Program Requirements

1. a) Females aged 18+ At least 50% of the family (female applicants bringing children) must be of Indigenous ancestry.

b) Men aged 18+ Applicants must be of Indigenous ancestry.

c) Families – At least 50% of the family must be of Indigenous ancestry.

2.    Applicant must be in need of housing due to homelessness or at-risk of homelessness (i.e., living in a shelter, temporarily staying with family or friends, etc.).

3.    Applicant must be 18 years of age or older.

4.    Applicant must be eligible for Ontario Works, ODSP or other income programs, if not working or attending school or a training course.

5.    Applicant must be committed to paying service fees;

6.    Applicant must be committed to connecting with community resources and moving toward an independent and healthy lifestyle.

7.    Applicants must agree to sign our Consent to Obtain Information form with the referring community service agency and other service providers the applicant is working with.
C. Application Checklist
A. Applicant is of at least 18 years of age and currently in need of housing due to homelessness or at-risk of homelessness.B. Applicant is currently eligible for Ontario Works, ODSP or other income programs and if not, applicants must be working or attending school or a training course.C. Once housed, applicants are committed to paying the mandated and agreed upon service fees.D. Applicant understands that they are required to maintain sobriety and abstain from any alcohol or recreational (mood altering) drugs for the duration of their stay in BNH’s transitional housing program.E. The Applicant(s) must provide two (2) identification proofs. ex. driver's license, Native Status Card, band letter, passport, brith certificate.F. The Applicant(s) must provide proof of Indigenous ancestryG. Family applicant’s who are applying for housing and have children must provide some proof of child custody (for all children under the age of 18).H. The Applicant must complete this entire Application Form including the Consent to Obtain and Disclose Information section of the Application Form.
Mandatory Documents

As mentioned in bullets E.,F. & G. above, the applicant(s) are required to submit the following:
1. Identification Proof (2)
2. Proof of Indigenous ancestry
3. Proof of Child custody (if applicable)
Please Upload all Mandatory Documents Here:

Cancelof
Transitional Housing Program Application Form

Form Begins
Transitional Housing Facility Descriptions:

Karahkwa House is geared to supporting Indigenous men and sexually diverse populations recover from alcohol or drug use and who want to learn to maintain their sobriety.

Ehnita House is geared to supporting Indigenous women and sexually diverse populations between the ages of 18-24.

Ojistoh House is geared to supporting Indigenous women and sexual diverse populations over the age of 25 with or without children. Ojistoh house operates through two streams;

Odehaot House is geared to supporting families with children to stay for up to 1 year while focusing on finding affordable housing in the community.
Please select the following transitional housing facility that you wish to apply for:
1.0 REFERRING AGENCY INFORMATION

Is anyone referring you to Brantford Native Housing?
Name of Agency:
Name/Position:
Agency Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency telephone, fax and email information:
2.0 APPLICANT INFORMATION

About the Applicant
Name:

First NameLast Name
Date of Birth:

MonthDayYear
enter birthdate
Indigenous Ancestry:
Applicant Band and Number if known:
Applicant Current Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant Phone Number or Alternative contact phone number:
Please enter a valid phone number.
Applicant Email or Alternative Contact Email:
example@example.com
Name of Alternative Contact if used
Co-Applicant Name (if applicable):

First NameLast Name
Co-Applicant Date of Birth (if applicable):

MonthDayYear
Date
Co-Applicant Indigenous Ancestry (if applicable):
Co-Applicant Band Number if known (if applicable):
Co-Applicant Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Co-applicant Phone Number:
Please enter a valid phone number.
Co-applicant Email Address:
example@example.com
Applicant Dependents. Include each dependent's (child) name, gender, age, Indigenous Ancestry and date of birth:
Primary SchoolSome High SchoolHigh School - graduateGEDSome CollegeCollege - graduateSome UniversityUniversity - graduateTechnical Trade certifiedTraining
Some High SchoolHigh School - graduateGEDSome CollegeCollege - graduateSome UniversityUniversity - graduateTechnical Trade certifiedTraining
YesNo
If the Applicant is employed, please indicate your employer, address of employment, telephone and email:
What is the Applicant's current Position?
How many weekly hours does the Applicant work?
Please describe any other sources of income:
YesNo
YesNo
If the Co-Applicant (if applicable) is employed, please indicate your employer, address of employment, telephone and email:
What is the Co- Applicant's (if applicable) current Position?
How many weekly hours does the Co- Applicant (if applicable) work?
Please describe any other Co-Applicant (if applicable) sources of income:
YesNo
YesNo
YesNo
If Yes, How Long has the Applicant(s) been homeless?
YesNo
YesNo
What Best Describes the Applicant(s) current living situation
YesNo
Restraining orderPeace BondsCustody ordersCAS conditionsOther
If Yes, Please Explain further:
YesNo
If Yes, which Applicant(s) is on probation or Parole?
If Yes, Please provide the probation/parole officers name and contact information:
Ontario WorksCASProbation / ParoleMental Health SupportsCounselling / TherapyLegal ServicesPublic Health ServicesTraining ServicesEmployment ServicesDrug and/or substitution programsBehaviour ManagementCultural ProgramsOther
Please describe the services selected / in use below:
What Goals do the Applicant(s) want to work on while housed with BNH?
3.0 CLIENT EMERGENCY & HEALTH INFORMATION

Emergency Contacts
Applicant(s) Emergency Contact Person:

First NameLast Name
Relationship to Emergency Contact:
Contact Information of Applicant(s) Emergency Contact:
Who does the Applicant(s) include as support during crisis? Please include their names, relationship and contact information:
When did the Applicant(s) last see a doctor?
Doctor's name:

First NameLast Name
Doctor's Contact information & Address:
Does the Applicant(s) have any life threatening allergies? If Yes, please explain:
If the Applicant(s) has any allergies, do you carry an Epi-pen on you?
Please add any additional information that will assist our understanding of the Applicant(s) needs:
Brantford Native Housing Consent to Obtain and Disclose Information Form

Please read and sign
What is “Personal Information”?

Personal information includes any factual or subjective information, recorded or not, about an identifiable individual. This includes information in any form, such as:
- age, name, social status, income, assets, residency status, Indigenous ancestry, rent payment record, etc;
- opinions, comments, evaluations and observations.
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Collection and Use of Your Personal Information

Brantford Native Housing staff will collect, retain and use the personal information provided by you in this form and its attachments for the following purposes:
- considering your application for residential eligibility;
- verifying the information that you have provided in your application and its attachments relating to the administration and processing of your application for residency;
- calculating your rent and the collection of your rent;
- meeting legal and regulatory requirements arising out of or relating to your residency;
- for the use of Brantford Native Housing’s auditor to verify our financial records;
- for the purpose of contacting necessary services on your next-of-kin in case of emergency;
- for the purpose of cooperative effort in service provision and case management;
- for the purpose of making repairs or renovations to the residential unit.
Brantford Native Housing will disclose the personal information provided by you in this form to the following parties for the purposes as outlined above:
- to any social agency providing any form of assistance to you, or other government subsidy under the Ontario Works Act, 1997, the Ontario Disability Support Program Act, 1997, or the Day Nurseries Act, or any government department responsible for social housing programs under the Residential Tenancies Act, or Brantford Native Housing’s housing portfolio operating agreement;
- to the Government of Canada, a department, ministry or agency of it, without further notice to me if the information is necessary for the purpose of administering or enforcing the Income Tax Act (Canada), the Immigration Act; the Health Protection and Promotion Act and the Child and Family Services Act;
- to any agent working on behalf of Brantford Native Housing for the purpose of complying with the Residential Tenancies Act;
- to any agent/contractor working on behalf of Brantford Native Housing to make repairs or improvements to the facility or unit;
- to relevant agencies or next-of-kin in case of emergency;
- to relevant agencies to assist in the cooperative effort and delivery of services, and inclusive of the Mental Health Act;
- to credit bureaus, other business or individuals that provide credit or rental history information about you;
- to the City of Brantford - Housing Department for any damage or rental arrears left after vacating the residential unit and to Financial Institutions for the collection of rent;
The Executive Director of Brantford Native Housing, located at 318 Colborne Street, Brantford, Ontario, N3S 3M9, 519-756-2205 can answer questions and respond to complaints about the collection, use or disclosure of the information.

_____________________

Consent

I authorize and agree that Brantford Native Housing may collect, use and disclose the personal information that I have provided in this form and its attachments as described above as well as dispose of personal information. I understand and acknowledge that, in addition to the foregoing, Brantford Native Housing, will also collect and use and disclose my personal information as required for the purposes and intentions of meeting legal obligations and in the performance of duties as/or permitted by law.
Applicant Signature
Co-Applicant Signature (if applicable)
Referring Agency Signature
Date

MonthDayYear
Date of Signing
Should be Empty:

Brantford Native Housing Transitional Housing Program

BNH Office Address

Mandatory Documents

Transitional Housing Program Application Form

1.0 REFERRING AGENCY INFORMATION

2.0 APPLICANT INFORMATION

3.0 CLIENT EMERGENCY & HEALTH INFORMATION

Brantford Native Housing Consent to Obtain and Disclose Information Form

Collection and Use of Your Personal Information

_____________________

Consent