General Information

Present Situation

Financial Situation

Living With Others

Activities

Medical History

History of Criminal Offences

References

Referred to Gladstone House By

RESIDENTIAL APPLICATION:

Please complete all aspects of the Gladstone House Application Package. Incomplete applications will not be processed.

Full Name

Telephone

Address

How long have you been at this address?

Reason for leaving present address?

Have you ever lived in a second stage home?
YES NO

From

To

Gender

Date of Birth

Age

First choice language spoken

Second choice language spoken

Name

Relationship to applicant

Address

Telephone home

Telephone business

At the present time I live:
With friends With family Alone Within a group Program

Cost of accommondation

Name of landlord

Landlord telephone

Please indicate gross income per month (enter 0 if none)

Employment

OWA

ODSP

Pension

Personal Savings

OSAP

Insurance Benefits

Living allowance

Other

If your income is OWA or ODSP, provide the name/phone # of you worker

Name

Telephone

Days and times to reach your worker

Have you lived in a group setting prior to this date?
YES NO

If yes, with whom?

Why do you want to live at the S.A. Gladstone House?

How do you feel about sharing a kitchen/living room/bathroom?

Please check activites in which you are involved
Volunteer work
Employment
School/Training
Recreation
Therapy
AA/NA meetings
Support group
Life skills training

Name each of the agencies/schools/employers/meetings/therapists/etc...

State the days & times of involvement in each activity

Name of family doctor

Telephone

Address

Do you live with a medical condition of any kind? (Diabetes, Heart condition, hepatitis, etc...)
YES NO

If yes, please specify

Do you live with an emotional and/or mental health diagnosis?
YES NO

If yes, what is your diagnosis?

Name of psychiatrist/psychologist

How often do you see your psychiatrist/psychologist

Are you currently taking medication
YES NO

If yes, what medication?

How long have you been taking medication?

When do you take your medication?

Do you have a social worker for additional support?
YES NO

Social worker name

Social worker agency

Social worker telephone

Do you live with an addiction diagnosis?
YES NO

If yes, what is your substance(s) of choice?

How long have you not used drugs and/or alcohol?

Are you receiving counselling at this time?
YES NO

Name of agency or centre

Name of counsellor

Telephone

Are you on probation/parole?
YES NO

If yes, list offence(s) and time probation/parole is completed

List any offences for which you were charged or convicted in the past ten years

Name of probation/parole officer

Telephone

You must provide 3 references with accurate phone numbers (Friends and family members excluded).

Landlord

Telephone

Psychiatrist/Psychologist

Telephone

Social Worker/Counselor

Telephone

Outreach Worker

Telephone

Family Doctor

Telephone

Employer

Telephone

Volunteer Supervisor

Telephone

Teacher

Telephone

Other

Telephone

Referred to Gladstone House by:

Name

Telephone

Agency (if applicable)

If someone other than the applicant has filled out this application, please complete the following:

Name

Title

Organization

Type the numbers

I certify that the information provided is correct. I understand that any misleading information could be grounds for termination of the Gladstone House application process and/or residency.

Submit Application