Chandler Street Housing Program

Application Package

Our mission at Inn from the Cold-Kelowna (IFTC) is to respond to people who are experiencing, or are at risk of homelessness, in a welcoming, compassionate and mutually respectful manner.

IFTC is now accepting referrals for permanent housing for our new housing program at 1829 Chandler Street. This 8 bedroom buildingwill offer low-barrier housing for men experiencing chronic homelessness.

Our home will be modeled based on the Housing First approach that supports the concept of securing housing as the first step of transitioning out of homelessness. We believe that obtaining safe and supportive housing provides the foundation for individuals to stabilize and begin to work on their individual self-care.There will be no readiness requirements other than experiencing chronic homelessness and a willingness to live and participate in a community living environment.

To further remove barriers and increase accessibility for some of our most vulnerable community members, our facility will consider accepting individuals with pets that are conducive to supporting a healthy living environment.

Rent will be $475 and $500 depending on the size of the room. As well as a home with staff support we plan to provide the evening community meal with support from the Kelowna Food Bank.

Application forms can be printed from our website: and either faxed to 778-478-3690 or emailed to .

Authorization for Release of Information

To be reviewed and signed by applicant and referring agent

In order to complete your application forInn from the Cold—Kelowna’s housing program, your caseworker will be completing the application with you and sharing your personal information with Inn from the Cold—Kelowna. The information shared will remain confidential and is collected and protected according to the Personal Information Protection Act and Freedom of Information Act.

If your initial application does not result in housing, it will be kept on file for one month; please advise us if you have found housing within that time. Otherwise, we will dispose of your application package and you will need to reapply the next time we have a call for applications.

I have read and understand the above information.

Date______

Applicant Signature______

Applicant Name (print)______

Referring Caseworker Signature______

Referring Caseworker Name (print)______

REFERRAL INFORMATION

Referring Agency
Worker Name / Position
Telephone # / Email Address

APPLICANT INFORMATION

Last Name, First Name
Alias/Street Name
Date of Birth / Pet / dog cat
caged pet none
Emergency Contact, Relationship / Contact #
How long have you worked with applicant and in what capacity?
Have they expressed a preference for community living? Why do you think the applicant would be a good fit for this housing program?

ADDITIONAL SUPPORTS

Physician / Psychiatrist
A&D Clinician / Mental Health Worker
Probation Officer / Parole Officer
Friends/Family
Other Supports

HOUSING HISTORY

How long has applicant lived in this community?
How long has applicant experienced absolute (shelter/street) homelessness?
Has the applicant lived in a community/shared accommodation setting in the past? Yes No
If yes, what did and didn’t work in that living situation?
Please provide housing history over the past two years.
Current living situation (select one)
Camping/Street / Pending eviction / Recovery/Mental Health Group Home
Shelter / Hospital-waiting discharge / Motel
Inadequate or unsafe housing (boarding house, pickers shack, camper) / Detox/Residential Treatment / Staying with friends/family
Other, specify:
What is preventing the applicant from securing housing (select all that apply)?
Insufficient income/finances / Active substance abuse / Behavior not conductive to living with others
No references / Mental Health issues / Has pet(s)
Missing Identification / Language Barriers / Other, specify:

PHYSICAL HEALTH HISTORY

Please comment on the physical health of the applicant. Please include relevant information regarding chronic and acute health issues, history of seizures, head trauma, mobility issues, etc.
Current Medications
Medication / Dosage / Purpose / Approx. Start Date
Does applicant take medication regularly as prescribed?
If yes, please describe. / Yes / No

MENTAL HEALTH HISTORY

Stated Diagnosis / Anxiety / Borderline Personality Disorder / Post-Traumatic Stress Disorder
Depression / ADHD / Schizophrenia
Bipolar / Psychosis / Other
Details/Comments
Observed Behaviors / Hallucinations / Paranoia / Isolates self
Self-harm / Violent outbursts / Talking to self
Other
Details/Comments

SUBSTANCE USE HISTORY

Does applicant currently use alcohol or other substances? / Yes / No
Does applicant have a history of substance misuse? / Yes / No
Substance Use / Crack / Heroin / Crystal Meth
Alcohol / Inhalants / Alcohol Substitutes
Cocaine / Marijuana / Other
Drug of Choice
Other addiction? (ie, gambling, sex, gaming). If yes please specify. / Yes / No
Is applicant on methadose or suboxone maintenance program? If yes, please provide start date & dosage. / Yes / No

SOURCE OF INCOME

Source of Income / Amount
Income Assistance (IA)
Income Assistance (PPMB)
Income Assistance (PWD)
Employment Assistance (EI)
Income top-up (volunteer work)
Canada Pension Plan (CPP)
Old Age Security (OAS)
WorkSafe BC
INAC Band
Employment
Other
Deductions
Total Income

LIFESKILLS ASSESSMENT

Please comment on the applicant’s ability meet his nutritional needs; please consider ability to budget, prepare, and safely store food.
Please comment on the applicant’s ability to maintain living quarters.
Please comment on the applicant’s ability to maintain personal hygiene.
Please comment on applicants special interests and/or hobbies.

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Inn from the Cold – Kelowna

PO Box 21130 Orchard Park PO Kelowna BC V1Y 9N8

(Phn) 250-448-6403 (fax) 778-478-3690