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.

 

Please note: It is important that you answer all the questions this will enable us to determine your eligibility for residency.
 

    A. Personal Information





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


    Is it safe to email you: YN

    5. Preferred method of contact PhoneEmail

    7. Self-Referral: YN or

    9. Do you require cultural interpretation for an interview? YN

    10. Please list the names, birth dates and gender of any children living with you and not living with you:

    Living with you: YN


    Living with you: YN


    Living with you: YN


    Living with you: YN


    Living with you: YN


    11. Are you currently involved with Children’s Aid? YN

    12. Status in Canada:
    Canadian CitizenLanded Immigrant/Permanent ResidentRefugee ClaimantNo Status

    13. How did you find out about Harmony House?
    Shelter staffCommunity support workerHealth care professionalFriendOther

    14. Do you have any health problems or limitations we should be aware of?

    15. Have you and/or your children come into contact with bed bugs? YN
    If yes, have you followed the bed bug protocol: YN

    16. Do you have pets? 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


    1. Income Source

    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



    3. Do you have a public trustee? 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

    2. Does this person have access to guns or other weapons? YN

    3. Has this person ever threatened to kill you, your children or others? YN

    5. Have any charges been laid? YN

    6. Do you have any of the following orders in place?
    Peace BondRestraining OrderCustody



    F. NEEDS ASSESSMENT


    1. What kinds of supports do you feel you need?

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    NEXT STEPS (IMPORTANT):

    Once we receive this complete application the Women’s Advocate will contact the applicant to confirm any additional info needed. Please note that Harmony House has a dynamic waitlist therefore; the Women’s Advocate will continuously contact you throughout the waiting period to determine your continued interest.

    If you are approved for residency, the Women’s Advocate will contact, you to schedule an interview.

    ******* If we do not get a response after calling and/or emailing you THREE times your name will be
    automatically removed from the waitlist so please email or call if your info changes.

    If someone assisted, you in filling out this application form please state their name and their relationship to you.