Please enable JavaScript in your browser to complete this form. - Step 1 of 12General InformationName *Address *Phone *Email *Date of Birth *Sk. Hospitalization Number *Gender *MaleFemaleTransgenderMarital Status *SingleMarriedWidow(er)DivorcedCommon-lawOtherAboriginal StatusFirst NationsInuitMetisNon-statusNon-indigenousCitizenship *CanadianPermanent Resident/ImmigrantRefugeeStudent VisaPlace of Birth *Veteran *NoYesVeteran *Canadian Armed ForcesFormer RCMPNextFinancial SituationSource(s) of Income (i.e. Pension, Employment, Social Services, etc.)? *Approximate Monthly Income? *PreviousNextEducation and Work ExperienceHighest level of schooling completed? *At what age? *Where? *Specialized Vocational Training? *PreviousNextWork ExperienceHave you worked within the last year? *Where? *What jobs have you held in the past? *PreviousNextSocial SituationWho does your support system consist of? (i.e. friends, family, relatives, groups, etc.). *What are your hobbies or areas of interest and how do you spend your time (day and evening)? *PreviousNextOtherHow frequently do you use alcohol? *NeverSeldomOccasionallyWeeklyDailyHow frequently do you use drugs, other than those prescribed to you? *NeverSeldomOccasionallyWeeklyDailyDo you have outstanding criminal charges? *Do you have difficulty managing your anger? *PreviousNextPrevious Living SituationsPlease list your current living situation, and living situations over the past five years (i.e. apartment, Approved Home, Group home, etc.) *Have you ever been evicted? If so, please explain *Please check off the skill areas you would like to improve *Money ManagementGrocery ShoppingCooking/NutritionMedication ManagementIllness AwarenessPersonal HygieneHousekeeping SkillsSocial SkillsAssertivenessDaily Structure/RoutineVocational SkillsCommunity InvolvementProblem SolvingWhat do you expect to gain from living here? *PreviousNextPlans for the FutureTraining/Education *Employment *Social Life *PreviousNextCommunity ContactFamily Doctor (Name & Phone) *Family Doctor (For how long and how often?) *Psychiatrist (Name & Phone) *Psychiatrist (For how long and how often?) *CMHN (Nurse) - Name & Phone *CMHN (Nurse) - For how long and how often? *Crisis Management Worker (Name & Phone?) *Crisis Management Worker (For how long and how often?) *Financial Worker (Name & Phone) *Financial Worker (For how long and how often?) *Case Manager/Service Coordinator (Name & Phone) *Case Manager/Service Coordinator (For how long and how often?) *Other (Name & Phone) *Other (For how long and how often?) *PreviousNextMedicalWhat is your diagnosis? *Please provide a brief description of how your illness affects you, including side effects, symptoms, etc *What medication(s) are you taking and what are the dosages? *How long have you been taking these medications? *Do you administer your own medication? *YesNoFor how long? *When was your most recent *Physical ExaminationDental CheckupOptical ExaminationPlease list any other physical/medical problems (including allergies)? *Do you have any contagious or infectious diseases: (ex: HIV, AIDS, MRSA, Hepatitis, etc) *How many times have you been hospitalized?In the last year *YesNoFor what reason *In the last five years *YesNoFor what reason *PreviousNextIn Case of EmergencyName *Relationship *Address *TelephoneHome *WorkCellDo you have any questions or concerns? *PreviousNextFor the Supportive Apartment Program, please provide two (2) landlord references.1Landlord's Name *Phone Number *Your Previous Address *When did you live there and for how long? *2Landlord's Name *Phone Number *Your Previous Address *When did you live there and for how long? *I understand that this application will not be processed unless all questions are fully answered. *I understand that this application will not be processed unless all questions are fully answered. * This application will not be processed unless all questions are fully answered. Written verification of income may be required before this application is processed. This application does not constitute an agreement on the part of North Star Supportive Housing to provide me with a housing unit. North Star Supportive Housing may at any time prior to the signing of the lease, withdraw or cancel approval of this application without penalty. Information contained in this application form is confidential. However, I give authorization for North Star Supportive Housing to make inquiries to verify the facts which relate to the provision of NSSH’s services. It is your responsibility to keep our office updated on any changes on your application. ALL APPLICATIONS REMAIN ON FILE FOR A ONE (1) YEAR PERIOD and will need to be resubmitted after that date. Captcha * = PreviousPhoneSubmit
