Choices for Change 10 Downie Street 3rd Floor Stratford, ON N5A 7K4 Phone: (519) 271-6730 ext. 218 (Perth) - (519)-271-6730 ext. 302 (Huron) Fax: (519) 271-2746 Addictions Supportive Housing (ASH) Huron-Perth APPLICATION FORM A. Client Information Name (first and last): Last Name at Birth (if different): Date of Birth (dd/mm/yy) Gender: Relationship Status: Applicant has fixed address? Female Male Other Yes No Street Address Apt. / Unit City Postal Code Personal Phone Number OK to call? OK to leave Call Restrictions message? ( ) Yes No Yes No Emergency Contact: OK to call? OK to leave Emergency Contact phone number: message? ( ) Relationship: Yes No Yes No Email Address: Preferred Language of Service English French Other: B. Program Information Has applicant participated in ASH before? Did applicant complete program? Does applicant smoke? Yes No Yes No Yes No Date of entry (dd/mm/yy): If no, please explain: Applicant understands that no smoking is Does the applicant have a pet? allowed inside the ASH apartments: Yes No Yes No Is yes, please report what kind of pet and how many. Please note Applicant Initials: this may impact housing options and wait time for apartment. Income Source: Monthly income: Name of OW/ODSP Case worker: Applicant approves direct payment to housing: $___________ Yes No C. Dependents (please list all dependents) Name (full name) Date of Birth Gender Currently in Care? (Yes or (dd/mm/yyyy) No) Yes No
Choices for Change 10 Downie Street 3rd Floor Stratford, ON N5A 7K4 Phone: (519) 271-6730 ext. 218 (Perth) - (519)-271-6730 ext. 302 (Huron) Fax: (519) 271-2746 Addictions Supportive Housing (ASH) Huron-Perth APPLICATION FORM A. Client Information Name (first and last): Last Name at Birth (if different): Date of Birth (dd/mm/yy) Gender: Female Male Other Relationship Status: Applicant has fixed address? Yes No Street Address Apt. / Unit City Postal Code Personal Phone Number ( ) OK to call? Yes No OK to leave message? Yes No Call Restrictions Emergency Contact: Relationship: OK to call? Yes No OK to leave message? Yes No Emergency Contact phone number: ( ) Email Address: Preferred Language of Service English French Other: B. Program Information Has applicant participated in ASH before? Yes No Date of entry (dd/mm/yy): Did applicant complete program? Yes No If no, please explain: Does applicant smoke? Yes No Applicant understands that no smoking is allowed inside the ASH apartments: Yes No Applicant Initials: Does the applicant have a pet? Yes No Is yes, please report what kind of pet and how many. Please note this may impact housing options and wait time for apartment. Income Source: Monthly income: $___________ Name of OW/ODSP Case worker: Applicant approves direct payment to housing: Yes No C. Dependents (please list all dependents) Name (full name) Date of Birth (dd/mm/yyyy) Gender Currently in Care? (Yes or No) Yes No
ASH-Application-2017.docx