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432 Springbank Ave. N #20. Woodstock. ON. N4T 1N7 Phone: 519.421.0383 Fax: 519.421.0955

TRANSITIONAL HOUSING APPLICATION FORM

WELCOME! Ingamo Homes is Second Stage Housing for women with or without children who are survivors of violence. With this application you can be considered for transitional supports and housing with

Ingamo Homes. The purpose of the questions is to help us learn more about you and assess what your particular needs are, so please answer them completely and accurately. It is our preference for you and this process that this form be completed with an “ending violence against women” worker.

Having this assistance can support you in many ways, including immediate safety planning, support, options, resources and referrals.

The completed and signed form should be faxed or mailed to the above address. You do not need to send this information sheet with your application.

Your application will be processed efficiently, respectfully and in confidence. The application interview will be arranged with you in the near future, so please ensure we have accurate contact information.

As the interview includes adult discussions regarding abuse, you will need to make childcare arrangements. For this meeting please bring the following:

• Birth certificate for all persons who may be residing in the program • Income verification

• Full name, address and phone # of emergency contacts (2)

PLEASE RETAIN THIS SHEET FOR YOUR OWN REFERENCE.

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INGAMO STAFF USE ONLY: Interview Date: ___________________________WISH #_____________

A. PERSONAL INFORMATION:

1. Full Name: _______________________________________________________________________

2. Alternate Name(s_______________________________________ DOB (dd/mm/yy) ____/____/____

3. Current Address ___________________________________________________________________

4. Current Telephone Number _________________________________Safe to leave message? Y / N

Cell number ____________________________________________ Safe to leave message? Y / N

Email address __________________________________________ Safe to send message? Y / N

5. Safe Alternate Contact Name and Number______________________________________________

Relationship/Agency _______________________________________________________________

6. Vehicle information:

Make: ______________ Model: _________________ Year: ___________ Colour: _____________ License Plate: __________________Driver’s License: ____________________________________

7. Preferred language_________________________________________________________________

Do you require cultural interpretation for the interview? Y / N If Yes, which language? _______________________Country of Origin: _______________________

8. Physical Description: Please fill in/circle the most appropriate description.

Weight Height Build Extra-Large, Large, Medium, Petite, Small Eye Colour Blue, Blue-Brown, Brown-Hazel, Dark Brown, Green, Hazel, Hazel-Blue, Other Hair Colour Auburn, Black, Blonde, Brown, Dark Brown, Grey, Light Brown, Red, Salt and

Pepper, Other Hair Length Long, Medium, Short, Shoulder length, Shaved, Bald Hair Style Afro, Braid, Bushy, Curly, Dreadlocks, Layered, One length, Short, Shaved,

Straight, Wavy Complexion Brown, Dark, Fair, Light, Medium Tattoos/Piercings

Distinguishing Features

Eyewear Glasses, Contacts Teeth Native/Aboriginal No, Non-Status Aboriginal, Status, Unknown

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9. Health information: Health card ______________________________________________________ Family Doctor ________________________ Location_______________________________________ Dentist ______________________________Location ______________________________________ Other Doctor _________________________ Location_______________________________________

Medication Reason Prescribed Any special health situations, allergies or limitations we should be aware of? Y / N If yes, please explain: ________________________________________________________________ __________________________________________________________________________________

10. Counselling/Support/Advocacy Services Agency Worker Reason

11. Status in Canada Canadian Citizen _______ Landed Immigrant _______ Refugee Claimant _______

12. How did you find out about Ingamo Homes?

Shelter Staff _________ Community Support Worker ______ _ Healthcare Professional ________

Friend _______ Website ________ Brochure ________Other (please list ) _________________

B. CURRENT HOUSING SITUATION 1. Are you currently homeless? Y / N

2. Where are you staying now?

Family / Friend ________ Abused Women’s Shelter _______ Motel _______ Hospital ________ Owned Residence ________ Rented Residence _________ Homeless Shelter _____________ Correctional Facility ________Other _________________________________________________

3. If you are applying from a shelter, what date did you enter? (dd /mm/yy) ___/___/___

4. If you are not applying from a shelter, what date did you leave the abuser?(dd/mm/yy) ___/___/___

5. Have you applied for subsidized housing through Oxford Social Housing or other communities?

Y / N If yes, what status have you received? Abuse Priority _________ Homeless __________

Urgent Needs ________ Chronological ________ Don’t Know __________

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C. CHILDREN’S INFORMATION

1. Please provide the following information for any children living with you:

Name M / F DOB Health card Medical/allergies

2. Please provide the following information for children not living with you:

Name M / F DOB Health card Medical/Allergies

3. Who has custody presently? ________________________________________________________

4. What are the arrangements? ________________________________________________________

5. Has there ever been threats to take the child (ren) ? Y / N By whom: _______________________ 6. Are you involved with CAS? Y / N Date involvement began ___________________________

Worker’s Name: ________________________ Number and Ext ____________________________

7. Do you have any upcoming Court Dates regarding custody, access or CAS? Y / N Date: _________________ Explain: _________________________________________________

8. Counselling/Support/Advocacy Services for Children:

Child’s Name Agency Worker Reason

9. Other Child related information we should be aware of:___________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

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D. INFORMATION REGARDING THE ABUSER 1. Full Name: ______________________________________________________________________

2. Alternate Names _________________________________________________________________

3. Date of Birth (dd/mm/yy) : ______ / ______ / ______

4. Present Address: _________________________________________________________________

5. Home Number: _________________________ Cell Number : _____________________________

6. Vehicle Information:

Make: _____________ Model: ___________ Year: __________ Colour: _____________________ License Plate: ________________ Driver’s License: _____________________________________

7. Is the abuser currently employed: Y / N List present or last place of employment: Occupation: ___________________________ Employer: _________________________________

8. Relationship to you: married_______ common-law _______ boyfriend _______ other ___________

9. Length of your relationship: _________________________________________________________

10. Physical description: Please fill in/circle the most appropriate description

Weight

Height Build Extra-Large Large Medium Petite Small Eye Colour Blue, Brown, Brown-Hazel, Dark Brown, Green, Hazel, Hazel-Blue,

Unknown Hair Colour Auburn, Black, Blonde, Brown, Dark Brown, Grey, Light Brown, Red, Salt

and Pepper, Other, Unknown Hair Length Bald, Long, Medium, Receding, Short, Shoulder Length, Shaved, Unknown Hair Style Afro, Braid, Bushy, Curly, Dread locks, Layered, One Length, Short,

Shaved, Straight, Wavy, Unknown Complexion Brown, Dark, Fair, Light, Medium, Unknown Facial Hair Tattoos/Piercings

Distinguishing Features

Native/Aboriginal No Non-Status Aboriginal Status Unknown

11. Can you provide a picture? Y / N

12. Does this person have access to guns or weapons? Y / N

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13. Has this person ever threatened to kill you, your children or others? Y / N If yes, please explain: _____________________________________________________________

14. Does this person use drugs or alcohol? Y / N 15. Is there any other way in which this person(s) is a danger to you and/or your children or others?

_______________________________________________________________________________

_______________________________________________________________________________

16. Have you ever needed to seek medical attention regarding the impact of the abuse? Y / N

If yes, please explain ______________________________________________________________

_______________________________________________________________________________

17. Have police laid charges against the abuser? Y / N If yes, please describe _____________________________________________________________ _______________________________________________________________________________

18. Has there been any police or court involvement? Y / N If yes, when and how many times? ___________________________________________________ _______________________________________________________________________________

19. Please list and explain any upcoming court date: ________________________________________ _______________________________________________________________________________

20. Do you have any of the following orders in place? Peace Bond ______________ Restraining Order ______________ Custody _______________

21. If police were involved, was the police intervention helpful to you? Y / N

22. Are you aware of any past criminal records / charges against the abuser? Y / N

What were they: _________________________________________________________________ _______________________________________________________________________________

23. Is there anything else you would like us to know about the abuser(s)?

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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E. TYPES OF ABUSE 1. Have you experienced any of the following? Please check all that apply and explain:

Form of Abuse (examples)

Once

Some

Lots

Comment/Examples

Isolation: (restricting your freedoms, keeping you away from family, friends, etc)

Male Privilege (treating you like a servant, demanding you obey, treating you like an inferior)

Threats & Psychological (threatening, harassment, stalking, depriving you of sleep or food, turning people against you, destruction of personal items)

Economic (withholding money or necessities, restricting you to an allowance, building up debts, making you account for your money, making you turn over earnings)

Intimidation (sudden mood changes, shouting, hitting or throwing things, killed or neglected animals/pets, giving you the silent treatment)to hurt you, assaulted you when you were

Emotional (insults, criticism, blaming, undermining your parenting, calling you names, putting you/appearance down)

Sexual (unwanted kissing or touching, withholding affection, excessively jealous, did not allow birth control, use of sex as a punishment, sex accompanied by violence or threats, pressured or forced sex)

Physical (threw you, punched you, bit you, shook you, pulled your hair, choked you, covered your mouth, threatened you with a weapon or used a weapon to hurt you, assaulted you when you were pregnant)

Spiritual ( stopped you from practicing or participating in spiritual exploration/ fulfillment, made fun of your convictions)

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2. Did you experience abuse not mentioned here? If so, please explain: ______________________

________________________________________________________________________________

________________________________________________________________________________

F. INCOME INFORMATION 1. Income Source

Source Monthly Amount

Ontario Works (OW)

Ontario Disability Support Program (ODSP)

Canada Pension (CPP) Disability

Employment Insurance (EI)

Salary / Wages

Insurance

Pension

Other

Total Monthly Income

Comments/Additional Information: _______________________________________________

____________________________________________________________________________

G. NEEDS 1. What kind of supports do you feel you need? Please check all that apply:

Legal _______ Housing _______ Financial _____ Counselling / Support / Advocacy ______ Medical _____ Parenting ______ Safety Planning _______ Community Resources _______ Other _______________________________________________________________________

2. Please tell us how living at a second stage shelter would be of benefit to you and/or your children: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. If someone assisted you in filling out this application form, please state their name and agency or relationship to you: Name: ________________________________________________________________________ Relationship/Agency: ____________________________________________________________

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DECLARATION

This is your agreement with us. Your confidentiality will be respected. Please read carefully before signing.

I have done my best to ensure that the information provided in this application is correct.

Applicant Signature___________________________________ Date: ___________________

FAX COMPLETED APPLICATION TO

519.421.0955

OR MAIL TO:

Ingamo Homes 432 Springbank Ave N., #20, Woodstock ON N4T 1N7