Chrysalis Supportive Housing

Huntsville, Ontario

Guidelines for Admission

Mission Statement:

Our mission is to enable vulnerable women to improve their quality of life through individualized support and transitional housing.

Program Goals:

  1. To provide affordable, safe, transitional housing (up to one year)for women and their dependent children.
  2. To support women in meeting their goals based on their personal strengths and their motivation for change.
  3. To offer nurturing, nonjudgmental, supported living for women.
  4. To help women access the community resources they need and want.
  5. To offer support, from within our community, to include the individual’s natural support system, volunteers and the Transition Worker.

Admission Application Process:

  1. Complete the Confidential Admission Application form.
  2. Send applications to: Robin Carson, Chrysalis, 12-56 Kinton Avenue, Huntsville, ON, P1H 1M3 or call (705) 789-8488 for further information.
  3. Consideration for transitional housing is dependant on available space, safety considerations, and the ability to live independently.
  4. Chrysalis Housing does not fall under the Residential Tenancy Act. A resident can be served with an Immediate Notice to Vacate where the agreed to rules have been broken and/or the safety of other resident are at risk.

Chrysalis Supportive Housing

Confidential Admission Application

Personal Information
Name: / Date:
Date of Birth: / Age:
Address:
Phone:
Alternate contact: / Phone:
How long have you lived in the Huntsville area?
Family Information
Do you have children?  Yes  No / If yes, how many?
Name / Age / Where do they live?
What School(s) do they attend?
Are there any medical or other concerns?
Is there a custody agreement?Yes No Please provide details:
Please tell us about your relationship with other family (parents, siblings, etc.)
Health Information
Do you have any health concerns?
Are you pregnant? YesNo / If yes, what is your due date?
Allergies:
Do you take any medications? If so, what are they and what are they prescribed for?
Do you have addiction issues? If so, what are your drugs of choice? Length of time clean?
Are you living with mental health challenges? If so, please describe.
Please list any medical professionals that you are involved with:
Doctor: / Phone:
Other: / Phone:
Other: / Phone:
Past and Present Agency/Community Contacts (during the past 12 months)
Agency Name / Date of Involvement / Reason and Outcome
Partner Relationship
Partner/spouse name: / Age:
Was this an abusive relationship? Yes No / Length of relationship:
How many times have you separated?
When did you separate and what has your partner’s reaction been?
Is there current contact with your partner? Yes No Please provide details.
Have you or your partner ever sought counseling? Yes No If yes, please provide details.
Have the police ever been involved in a domestic dispute or other situation? Yes No
If yes, please provide details.
Are you involved with the criminal or family justice system? Yes No
If yes, please provide details.
Do you have any safety concerns?
Are you currently in a relationship?
Abuse
Abusive relationships may be past or current. To help understand your fears and stress, it is important to go back to some of these painful times and identify. Have you experienced:
Emotional/psychological abuse
Physical abuse
Financial abuse
Sexual abuse
Financial Situation
Name of employer: / Phone:
Past employment and length of employment:
Are you receiving government assistance? Yes No
Check all that apply / Government Assistance / Monthly Amount





 / Ontario Works
Child Tax Credit
Child support
Disability allowance
Alimony
Other
Do you have any outstanding debt? Yes No If yes, please provide details.
Education
Are you currently in school? Yes No If yes, please provide details.
Highest education achieved: / Year:
Schools attended:
Difficulties in school:
Educational goals:
Present Situation
What is your current living situation?
Have you applied for District subsidized housing? Yes No / When?
Have you been looking for housing? Yes No If yes, please provide details.
Who recommended/referred Chrysalis housing to you?
Tell us about your support network. (Who? Where? How are you supported?)
References
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
References will be contacted.
How would you describe yourself? (strengths and weaknesses)
Goals/Action Plan
Short Term:
Goal / Steps/ Resourced Needed
1.
2.
3.
Long Term:
Goal / Steps/Resources Needed
1.
2.

Self Reflection

In your own words, tell us why you think Chrysalis will help your present situation.

______

What do you think some of your challenges may be during this transition period in your life?______

______

Check List – Form to be signed by staff and applicant after the interview / Please initial
1. Women and children only, no males are permitted in the building.
2. Rent is geared to income – all income needs to be reported.
3. All visitors must be pre-approved by staff.
4. Alcohol and drugs are not permitted on the premises.
5. Smoking is not permitted in the building.
6. No pets of any kind are allowed.
7. Residents must ensure their children are attended to and cared for at all times.
8. No overnight guests are allowed unless pre-approved by the Transition Worker.
9. Apartments must be kept clean and will be inspected with 24 hour notice.
10. Failure to comply with the rules/and or failure to pay rent can result in termination from the Housing Program.
11. Resident agrees to maintain the Action Plan assigned while residing at Chrysalis.
12. To reside at Chrysalis, monthly group and individual meetings are a requirement as well as one life skill workshop per month.
Do you understand the commitment of living at Chrysalis? Yes No
Are you willing to work on goals with the Transition Worker and volunteers? Yes No
Do you have any questions or concerns about living in transitional housing?

Signature:______Date:______

Transition Worker:______Date:______

Office Use Only

File # ______

Name of Applicant ______

Date of Application______

Referral source______

Date of Committee Review______

Admission approved Yes ______No ______

Committee recommendations and referrals or applicant withdrew and reason:

______

______

Apartment offered # ______

Move in date ______

Move out date ______

Resident Contract signed□Copies given to resident signed□

Action Plan signed□Confidentiality consent signed□

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