Transitional Housing Application Form
Personal Information
Name
*
First Name
Last Name
Preferred Pronouns
*
Birthday
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your first language?
*
Interpreter Required?
*
Yes
No
Status
*
Please Select
Canadian Citizen
Indigenous
Permanent Resident
Convention Refugee
Refugee Claimant
No Status
Have you applied to this program before?
No
Yes
Housing
Are you currently in a shelter program or have been in the shelter system before?
Yes, currently in a shelter program
Yes, I have been in a shelter program before
No
Describe your current living situation:
*
Do you require a couple's room?
*
Yes
No
Given that this is a transitional program, what are your housing goals? Tell us 3.
*
Have you paid rent before?
Yes
No
Income
What is your source of Income?
*
Please Select
OW
ODSP
Employment
OSAP
CAS
None
Do you currently have any debt? If yes, please describe:
*
Demographics
In Canada, the term "Indigenous" includes First Nations, Inuit and Metis. Do you identify with any of these three groups?
*
Please Select
First Nations (Status, non-status, treaty, non-treaty)
Inuit
Metis
No
Unknown
Prefer not to answer
People often describe themselves by their race or racial background. Which race category best describes you?
*
Please Select
Arab, Middle Eastern, or West Asian
Black (African, African-Canadian, Afro-Caribbean)
East Asian (Chinese, Japanese, Korean)
First Nations, Inuit or Metis
Latin American
South Asian or Indo-Caribbean (Indian, Indo-Guyanese, Indo-Trinidadian, Pakistani, Sri Lankan)
Southeast Asian (Filipino, Malaysian, Singaporean, Thai, Vietnamese)
White (English, Greek, Italian, Portuguese, Russian, Slovakian)
Not listed
Prefer not to answer
More than one race category, or mixed race, or race not listed, please describe.
*
Employment
Please describe your current working situation. Include if you are working full-time, part-time, casual, training program or volunteer. Include details about the job or training program.
*
Are you currently receiving any employment related supports?
*
Yes
No
If yes, by whom?
Education
Currently in school?
*
Please Select
Yes
No
Full-time
Part-time
Name of School and Program
*
Last Grade Completed
*
Would you like to return to school?
*
Yes
No
Justice System Involvement. *Please note that this information will not have an impact on the outcome of your application.
Are you on probation?
*
Yes
No
If yes, what are the conditions?
*
Do you have any outstanding charges?
*
Yes
No
Do you require support in getting a lawyer?
*
Yes
No
Health
Do you have any physical health concerns?
*
Yes
No
If yes, please describe
*
Do you have any mental health concerns?
*
Yes
No
If yes, please describe.
*
Do you have any allergies? If yes, please describe.
*
Do you have an EPI Pen?
*
Yes
No
Do you currently use any substances? If yes, what is your substance of choice?
*
How often do you access emergency services?
*
Social Support
What does your social supports look like?
*
Are you currently receiving support from any community agencies? If yes please list all.
*
Pets *Please be advised that this is a pet friendly program.
Do you have any pets? If yes, what kind of animal?
*
Do you have any concerns with having pets onsite? If yes, please explain.
*
Community and Goals
Why are you interested in this program and what would you like to accomplish while residing here?
*
How do you think this program will benefit you?
*
How will you contribute to the YouthLink community?
*
What are three goals you would like to accomplish while in this program?
*
Is there anything else you would like us to know?
*
Submit application
Declaration of Applicant
Check below if to the best of your knowledge, you have provided the most accurate information in my application for YouthLink's transitional housing program. I also give consent for Youthlink staff to contact my referring worker.
Referral Form
Name of Referring Worker
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Agency
*
Position
*
Email
*
example@example.com
Why are you referring this young person to this program?
*
How do you think the applicant will benefit from the program?
*
What are the applicant's greatest strengths?
*
In what areas does the applicant require the supports when transitioning to independent housing?
*
Declaration of Referring Worker
To the best of my knowledge, I have provided the most accurate information in my referral for YouthLink's transitional housing program.
Submit
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