Harmony House

Women's Shelter

Residency Application

What is Harmony House?
Harmony House is a Second Stage Shelter residence for women and their children who are survivors of violence. We provide a transitional period from crisis shelter services to independent living in the community. We provide safe and affordable housing up to one year along with programs of individual and group support, accompaniment, advocacy, and referral.
Who is eligible to apply?
Residency is available to any women over the age of 16 with or without children who have already or are planning to exit an abusive relationship and need a community where you can build your skills to be independent.
Residency Requirement
Residents are required to pay rent based on income. Residents are required to participate in Harmony House Programming. If the resident does not currently have any income they will work with Harmony House staff and other referred agencies to supplement their rent.
Privacy Declaration
All personal information collected is confidential; it may be used anonymously for statistical purposes and, for service delivery by Harmony House Staff. No information will be shared with anyone outside of the organization without the permission of the applicant or when required by law.

    A. Personal Information





    Is it safe to leave a message at this number: YN


    Is it safe to email you: YN

    PhoneEmail


    YN or

    YN


    Name:

    YN


    YN


    YN


    Living with you: YN


    Living with you: YN


    YN


    Canadian CitizenLanded Immigrant/Permanent ResidentRefugee ClaimantNo Status


    Shelter staffCommunity support workerHealth care professionalFriendOther


    YN
    If yes, have you followed the bed bug protocol: YN

    YN
    If yes, do you have somewhere safe for your animal to go? YN


    B. Current Housing Situation


    1. Are you currently Homeless?
    YN

    2. Where are you staying now:
    HospitalFamily/FriendHomeless ShelterAbused Women’s Emergency ShelterMotelCorrectional FacilityAt Home and/or with AbuserOther


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

    If yes when is a good time to contact, you:

    Time:  
     

    6. Have you applied for subsidized housing through the Social Housing Registry of Ottawa: YN

    7. If yes, what status have you received?
    Special PriorityUrgent-Safety PriorityMedical PriorityHomeless StatusChronologicalDon’t Know

    C. Income Information



    Harmony House supportive residency program operates from a rent-geared-to-income basis therefore; we need to ensure your ability to pay rent.

    **If you currently do not have an income you need to be willing to work with other agencies and staff to secure an income. Would you be willing to work with these agencies and staff on securing an income: YN

    Source/Monthly Amount


    YN




    D. Information Regarding The Abuse



    E. Types of Abuse Experienced


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


    OnceOccasionallyFrequently


    OnceOccasionallyFrequently


    OnceOccasionallyFrequently

    OnceOccasionallyFrequently


    OnceOccasionallyFrequently


    OnceOccasionallyFrequently


    OnceOccasionallyFrequently


    OnceOccasionallyFrequently

    YN


    YN


    YN


    Peace BondRestraining OrderCustody




    F. Needs Assessment

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo






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