Application for residency at Harmony House Shelter

Harmony House is a Second Stage transitional VAW (Violence Against Women) shelter that provides a safe place and supports for women with or without children, who are fleeing abuse.  As a Second Stage Shelter women live independently in their own unit and prepare their own meals in their own kitchen.  Residents are required to look for permanent housing once they are settled at Harmony House.

Before applying to live at Harmony House, please note the following:

• Residents are expected to live independently with minimal staff supervision. However, they are required to meet regularly with their frontline worker to ensure their needs are being met, and that their housing application for permanent housing is completed.
• As a supportive residency program Harmony House requires residents to pay rent geared-to-income.
• Once we receive your completed application our team will contact you to confirm any additional information needed.
• Please note that Harmony House has a dynamic waitlist; therefore, we will continuously contact you throughout the waiting period to determine your continued interest.
• If there is a change in the information you have provided on this application, you must inform us.
• Completing this application does not guarantee your placement in our residence.
• If you are approved for residency a member of our staff team will contact, you to schedule an interview.
• Safety Planning: At any time, you can contact our Outreach Worker at Outreach@HarmonyHouseWS.com to discuss a safety plan and access additional support.

 The information you give on the application form will be kept confidential.

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Please indicate the source of this referral: *Self-referralAgencyFriendFamily member

Please choose who is making this application for shelter.

If this is an agency referral:

Worker's/officer's name:

First

Last

Agency Name:

Please enter the name of your agency.

Worker’s / officer’s phone:

Please enter a phone number suitable for contact.

Worker’s / officer’s email:

Email

Confirm Email

Please enter an email address where we may contact the referrer.

If friend or family member:

Name: *

First

Last

Phone number:

Please enter a phone number suitable for contact.

Email address:

Email

Confirm Email

Please enter an email address where we may contact the referrer.

Relationship to applicant:

Briefly describe your relationship with the applicant.

APPLICANT’S PERSONAL INFORMATION:

Name: *

First

Last

Current address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Current phone number: *

Please enter a phone number where you can be reached.

Is it safe to leave a message at this number?: *

• Yes
• No

Email address: *

Email

Confirm Email

Please enter an email address that you can access.

Is it safe to email you?: *

• Yes
• No

Preferred method of contact: *

• Phone
• Email

Alternate Safe Contact: *

First

Last

The name of an alternate whom we can safely contact.

Phone: *

The phone number of the alternate safe contact.

Relationship:ParentChildFriendRelativeSupport workerOther

The relationship between the alternate safe contact and the applicant.

If "Other" please describe:

Please describe the nature of the relationship if you chose "Other".

Do you require cultural interpretation for an interview?: *

• Yes
• No

If yes, which language?:

Please name the language for which interpretation will be required during an interview.

Country of origin:

Which specific country is this language from?

How many children do you have living with you?:

Enter a number from 0 (zero) to 10 (ten).

Child 1 Name *

First

Last

Enter the name of your first child.

Child 1’s date of birth

Enter the date of birth of child 1.

Child 1's gender

• Male
• Female
• Other

Does the child have any special needs?:

Please list any special needs here.

Child 2 Name *

First

Last

Enter the name of your second child.

Child 2’s date of birth

Enter the date of birth of child 2.

Child 2's gender

• Male
• Female
• Other

Does the child have any special needs?:

Please list any special needs here.

Child 3 Name *

First

Last

Enter the name of your third child.

Child 3’s date of birth

Enter the date of birth of child 3.

Child 3's gender

• Male
• Female
• Other

Does the child have any special needs?:

Please list any special needs here.

Child 4 Name *

First

Last

Enter the name of your fourth child.

Child 4’s date of birth

Enter the date of birth of child 4.

gender danger If

Child 4's gender

• Male
• Female
• Other

Does the child have any special needs?:

Please list any special needs here.

Child 5 Name *

First

Last

Enter the name of your fifth child.

Child 5’s date of birth

Enter the date of birth of child 5.

Child 5's gender

• Male
• Female
• Other

Does the child have any special needs?:

Please list any special needs here.

Child 6 Name *

First

Last

Enter the name of your sixth child.

Child 6’s date of birth

Enter the date of birth of child 6.

Child 6's gender

• Male
• Female
• Other

Does the child have any special needs?:

Please list any special needs here.

Child 7 Name *

First

Last

Enter the name of your seventh child.

Child 7’s date of birth

Enter the date of birth of child 7.

Child 7's gender

• Male
• Female
• Other

Does the child have any special needs?:

Please list any special needs here.

Child 8 Name *

First

Last

Enter the name of your eighth child.

Child 8’s date of birth

Enter the date of birth of child 8.

Child 8's gender

• Male
• Female
• Other

Does the child have any special needs?:

Please list any special needs here.

Child 9 Name *

First

Last

Enter the name of your ninth child.

Child 9’s date of birth

Enter the date of birth of child 9.

Child 9's gender

• Male
• Female
• Other

Does the child have any special needs?:

Please list any special needs here.

Child 10 Name *

First

Last

Enter the name of your tenth child.

Child 10’s date of birth

Enter the date of birth of child 10.

Child 10's gender

• Male
• Female
• Other

Does the child have any special needs?:

Please list any special needs here.

Do you have any special needs we should be aware of?: *

• Yes
• No

If yes, please explain:

B. CURRENT HOUSING SITUATION:

Are you currently Homeless?: *

• Yes
• No

Where are you staying now?: *

• Hospital
• Motel
• Family / Friend
• Correctional facility
• Homeless shelter
• Abused Women's Emergency Shelter
• At home and / or with Abuser
• Other

If "Other" please explain

What date did you leave the abusive relationship?

If you are still currently at home and/or with your abuser, when do you plan to leave?:

If you are applying from a shelter, what date were you admitted to that shelter?:

If you have not yet left or are planning to leave, would you like assistance with making a safety plan/exiting plan?:

• Yes
• No

If yes when is a suitable time to contact you?:

Phone

Email

Email

Confirm Email

C. INFORMATION REGARDING THE ABUSE

Relationship to the person abusing you: *

TYPES OF ABUSE EXPERIENCED

Have you experienced any of the following? Please check all that apply.: *

• Isolation
• Controlling behaviours
• Threats and psychological abuse
• Economic abuse
• Intimidation
• Emotional abuse
• Sexual abuse
• Physical abuse

Does this person have access to guns or other weapons?:

• Yes
• No

Has this person ever threatened to kill you, your children, or others?:

• Yes
• No

Is there any other way in which this person(s) is a danger to you and /or your children?:

Please provide details.

Has there been police involvement?:

• Yes
• No

By submitting this residency application, you agree that:

• all information provided is true and complete to the best of your knowledge.
• Harmony House has the right to verify any of the information provided in this application to assess eligibility for second stage residency.
• It is your responsibility to inform Harmony House of any changes to contact.
• You may withdraw Consent anytime.

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