Application | Supportive Housing Solutions. Your Independence Matters.

Before we begin

Please fill out the application with as much information as possible. Incomplete or missing information will add to the processing time.

This application is for a congregate living setting. Please note that SupportiveLiving currently does not offer independent, self-contained apartment units.

Section 1 - REQUESTOR INFORMATION (PERSON FILLING OUT APPLICATION)

Name

Agency

Email Address

Business Phone (000-000-0000)

Ext.

Cell Phone (000-000-0000)

I give SupportiveLiving.ca permissions to add me to their mailing list to receive notifications of our housing availability in the future.

Please check the required fields

Section 2 - Applicant

Resident Name

Date Of Birth (DD/MM/YYYY)

Smoker/Non-Smoker

Health Card#

Version Code

EXP. (YYYY/MM/DD)

Identification

ID Type

SIN#

Marital Status

Sex

If other, please explain

Please check the required fields

Section 3 - Housing History

Have you lived in a congregate setting before? Y/N

If yes, when?

What is your current or last permanent living situation and explain reason for leaving.

Have you ever lost your housing in the past due to violent or aggressive behaviours? Y/N

If yes, describe behaviours or incidents:

Are you currently admitted to a hospital? Y/N

If yes, when were you admitted and the reason for admission:

Please check the required fields

Section 4 - Family Contacts

Primary Contact

Relationship

Street Address

City

Tel (000-000-0000)

Secondary Contact

Relationship

Street Address

City

Tel (000-000-0000)

Please check the required fields

Section 5 - Income

Primary Source of Income

Source

Amount

How often

Other Source Of Income

Amount & Notes

Do you have an Income Trustee? Y/N

Since When? (DD/MM/YYYY)

Do you require the services of an income trustee?: Y/N

Name

Tel (000-000-0000)

Ext.

Fax (000-000-0000)

Please check the required fields

Section 6 - Agency Information

Social service agencies you are a client of

Primary Agency or Organization

Agency

Street Address

City

Contact

Tel (000-000-0000)

Ext.

Fax (000-000-0000)

Secondary Agency or Organization

Agency

Street Address

City

Contact

Tel (000-000-0000)

Ext.

Fax (000-000-0000)

Please check the required fields

Section 7 - Incarcerations

Have you been incarcerated? Y/N

If yes, list reason and approximate dates.

Are you currently under a probation/recognizance order? Y/N

If yes, provide contact information of the probation officer:

Agency

Street Address

City

Contact

Tel (000-000-0000)

Ext.

Fax (000-000-0000)

Please check the required fields

Section 8 - Medical

Primary Medical Practitioner

Do you have a family Doctor?

Primary Doctors Name

Since (DD/MM/YYYY)

Address

Tel (000-000-0000)

Fax (000-000-0000)

Secondary Medical Practitioner

Secondary Doctors Name

Address

Specialty

Tel (000-000-0000)

Fax (000-000-0000)

Mobility

Do you currently experience mobility issues? Y/N

If yes, do you ambulate with the use of mobility aids? Y/N

If yes, please list mobility aids

Do you present as a fall risk? (This will help determine the most suitable housing placement) Y/N

If yes, please explain :

Pharmacy

Existing Pharmacy

Address

Tel (000-000-0000)

Fax (000-000-0000)

Do you/your client have aboriginal/indigenous status? Y/N

If yes, please provide the registry number on your Certificate of Indian Status Card :

Please check the required fields

Section 8 - Medical Conditions

Have you received the COVID-19 vaccination? Y/N

Allergies to medicine

Allergies to food

Are you visually impaired? Y/N

If yes, please explain :

Are you hearing impaired? Y/N

If yes, can you hear with the use of hearing aids? Y/N

Medical Conditions

Mental Health Diagnosis

When were you diagnosed (DD/MM/YYYY)

Specific behaviours/diagnosis

Diagnosing Doctor

Other Notes

Are you medication compliant? Y/N

Do you currently experience substance abuse or addiction issues? Y/N

If yes, list substances and most recent date of use/frequency :

Please check the required fields

Section 9 - Consents and Sign

I, , client of SupportiveLiving.ca, presently residing at , in the city of , give permission to any and all agencies and organizations for the release of information to SupportiveLiving.ca and its staff pertaining to my personal information, including but not limited to housing, medical, financial, diagnosis, medications, clinical assessments and reports, and any other information relevant to my admission and ongoing placement at a SupportiveLiving.ca residential home.

I have provided the above information to the best of my ability and know it to be true and correct. If any of the above information changes, I agree to notify the administration staff at SupportiveLiving.ca so this information can be updated. The below signed understands that this application is for the sole use of SupportiveLiving.ca and will be used in accordance with the Privacy act. Any sharing of this information will be limited to the housing of the resident and in case of emergencies.

I understand that for purposes of medication safety, my prescriptions will be transferred to the Pharmacy which SupportiveLiving.ca uses on a regular basis and hereby give my consent to SupportiveLiving.ca to requisition the transfer of my prescriptions upon acceptance of my application. I have read and understand all of the above consents OR all of the above consents have been explained to me.

Name

Date (DD/MM/YYYY)

Relation if not applicant

Please sign below

Clear

Please check the required fields

Apply

Before we begin

Section 1 - REQUESTOR INFORMATION (PERSON FILLING OUT APPLICATION)

Section 2 - Applicant

Section 3 - Housing History

Section 4 - Family Contacts

Section 5 - Income

Primary Source of Income

Case Manager of primary income source

Section 6 - Agency Information

Social service agencies you are a client of

Primary Agency or Organization

Secondary Agency or Organization

Section 7 - Incarcerations

Section 8 - Medical

Primary Medical Practitioner

Secondary Medical Practitioner

Mobility

Pharmacy

Section 8 - Medical Conditions

Section 9 - Consents and Sign