Home Base Housing 417 Bagot Street Kingston, ON K7K 3C1 tel: (613) 542-6672 fax: (613) 542-6317 www.kingstonhomebase.ca Youth Services 417 Bagot Street Kingston, ON K7K 3C1 tel: (613) 542-6672 fax: (613) 542-6317 info@kingstonhomebase.ca
Housing Help Centre 426 Barrie Street Kingston, ON K7K 3T9 tel: (613) 531-3779 fax: (613) 544-3629
housinghelp@kingstonhomebase.ca Supportive Housing Program
417 Bagot Street Kingston, ON K7K 3C1 tel: (613) 542-6672 fax: (613) 542-6317 info@kingstonhomebase.ca
In From The Cold Shelter 426 Barrie Street Kingston, ON K7K 3T9 tel: (613) 531-3779 fax: (613) 544-3629
housinghelp@kingstonhomebase.ca
A United Way member agency
Home Base Housing 417 Bagot Street Kingston, ON K7K 3C1 tel: (613) 542-6672 fax: (613) 542-6317 www.kingstonhomebase.ca Youth Services 417 Bagot Street Kingston, ON K7K 3C1 tel: (613) 542-6672 fax: (613) 542-6317 info@kingstonhomebase.ca
Housing Help Centre 426 Barrie Street Kingston, ON K7K 3T9 tel: (613) 531-3779 fax: (613) 544-3629
housinghelp@kingstonhomebase.ca Supportive Housing Program
417 Bagot Street Kingston, ON K7K 3C1 tel: (613) 542-6672 fax: (613) 542-6317 info@kingstonhomebase.ca
In From The Cold Shelter 426 Barrie Street Kingston, ON K7K 3T9 tel: (613) 531-3779 fax: (613) 544-3629
housinghelp@kingstonhomebase.ca
A United Way member agency
APPLICATION FORM FOR YOUTH SERVICES
Home Base Housing’s Youth Services program provides “supportive housing” for young men or women who require supports. If you live in our housing, a Case Manager will be assigned to you.
If you are interested in our housing, you must now complete this application form and return it to us. Let us know if you need help with any part of the application.
Once we receive the application form, a Case Manager will review your application to deem eligibility for the Youth Services program. Following this process, you will be contacted as to whether you meet our requirements for supportive housing or not. If you do, a time will be set up to complete a full assessment and to determine your level of support needed. Once the full assessment is complete, you be put on a wait list for a vacancy that is best suited to meet your needs. The time on the wait list may vary based on your situation and the availability of our housing.
Return the attached form to:
ATTN: Youth Services, Home Base Housing, 540 Montreal St, Kingston, K7K 3J2 or fax to 613-542-6317. You may also download the form to your computer and email to acarson@kingstonhomebase.ca.
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Home Base Housing – YOUTH SERVICES application
I am applying for : Adult Housing (20 and older) OR Youth Services (ages 16-24)
Applicant Name: Date of application:
Social Insurance Number (SIN) Date of Birth (d/m/yr)
Language Spoken Sex: Male Female
Transgendered Citizenship:
Do you have a permanent address that you currently live at? NO YES
If yes: complete below:
Current Address: ___________________________________ Unit:___________ City: __________________________ P.C. ____________
Telephone#: ________________ Other telephone: __________________ When did you move into this address? Month _______ Year ___________
If no: What is the best way to reach you?
Telephone: __________________ Email: __________________________________
Do you have a secondary contact? (Family member, friend, school, agency)
Name: _____________________________ Relationship: ________________________ Phone: _____________ Email: ____________________________________________ When did you move into this address? Month _______ Year ___________
It is important that you notify us if your contact information has changed. If you do not have a permanent address: Please describe your current living
arrangement. For example, are you living in a rooming house or are you staying with friends or family? Are you leaving the hospital or jail? Are you staying at a shelter or on the street?
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Home Base Housing - YOUTH SERVICES application.. continued
How long have you been living without a permanent address?
0-1 yr 1-4 yrs 4yrs+
In the past three years, how many times have you been homeless and then housed?
0-2 times 2-4 times 4+ times
I want (choose one) :
Housing Choice
Either shared or
I need a wheelchair accessible unit: NO YES
1 bedroom Shared housing only 1-bedroom only
Other preferences?
1. What is/are your source(s) of income?
General Information:
2. What is your gross monthly income? _______________/ month from all sources
3. Home Base Housing is geared towards single adults. Do you plan on living alone
if you move in (choose one)? YES NO NOT SURE
4. If housed, would you work regularly with a Case Manager?
YES NO NOT SURE
The following questions help us understand what the level and types of support you might need. Please answer honestly. Persons with higher needs are considered for our supportive housing first.
Support Needs:
1. Have you dealt with police, a crisis service or been to emergency in the past 3
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1-4 times 5-10 times more than 10
2. Have you assaulted someone or been assaulted in the last year? YES NO
3. Do you have any legal issues going on right now? YES NO
If yes, please explain:
4. Are you involved in any risky behavior, like running drugs, having unprotected sex,
exchanging sex for money or drugs, sharing needles?
YES NO
5. Where are you sleeping most often? Shelters ___ Streets ___ Vehicle ___
Waterfront ___ Other ___ (Please specify below)
___________________________________________________________
6. Do you make enough money to “get by” each month? YES NO
7. Do you do things during the day that you enjoy? YES NO
8. Are there people in your life that take advantage of you or that you spend time with
but don’t enjoy their company? YES NO
9. Where do you go for health care?
Hospital ___ Clinic ___ Street Health ____ Family Doctor _____ Other ____ Do not go ____
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If yes, describe:
11. Do you or have you had any medications prescribed to you that you do not take, sell,
have misplaced or haven’t had the prescription filled? YES NO
12.Have you experienced any trauma or abuse in your past that you think has resulted or
contributed to you being homeless? YES NO
13. Have you:
Ever had an addiction to drugs or alcohol, or been told you do? YES NO
Used drugs or alcohol every day for the past month? YES NO
Used injection drugs in the past six months? YES NO
Ever been treated for alcohol abuse and returned to drinking? YES NO
Drank anything like cough syrup, mouthwash, rubbing alcohol? YES NO
Blacked out after using drugs or alcohol? YES NO
Ever gone or been taken to hospital about a mental health concern? YES NO
Had a serious brain injury or head trauma? YES NO
Talked to a psychiatrist or professional about your mental health? YES NO
Ever been told you have a learning or other disability? YES NO
Are you or have you ever been in the care of a Children’s Aid Society?
b) If YES, would you be willing to work with a Youth In Transition Worker? (For youth in care or youth who were in care). YES NO
YES NO
c) If YES, Please sign below, which will allow Home Base Housing to share your information with the YITW who will be in contact with you.
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I, ___________________________ give consent to Home Base Housing to share my contact information with the Youth In Transition Worker through K3C.
Preferred method of contact:
⃝ Phone_______________ ⃝ Email:__________________ ⃝Text
only:_____________________
As part of the application process, we may need to speak with other people who know you. Please list names and contact numbers of other persons. Ideally, these are workers in agencies who have had recent contact with you.
Other supports and consents:
1 Name Title Agency Contact Tel (if
known) I give my consent to share information with the above person related to my application for supportive housing.
Signature: _______________________________ Date ________________________
2 Name Title Agency Contact Tel (if
Social Housing Registry
In order to live at Home Base Housing, applicants must qualify for Rent-Geared-To – Income (RGI) Housing. This is done through the Social Housing Registry.
• Have you qualified for RGI Housing? YES NO NOT SURE
• If you are not sure, may we have your permission to contact the Social Housing
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known) I give my consent to share information with the above person related to my application for supportive housing.
Signature: _______________________________ Date _______________________
3 Name Title Agency Contact Tel (if
known) I give my consent to share information with the above person related to my application for supportive housing.
Signature: _______________________________ Date _______________________
IMPORTANT: If you are assisting the applicant with this referral, please include your information in the chart above so we have permission to contact you.
Other Comments to Support My Application:
