1. Name: *
2. Pronoun: *
3. What is your gender identity? * 4. What is your cultural identity? * Do you identify as Indigenous? * If yes, which nation are you from? 5. Date of Birth: Age: * If you are under 19, who is your legal guardian?
We will not contact them before speaking with you.
6. Which region are you applying from? * Address:
7. Primary Phone Number: Email Address:
How would you prefer to be contacted? (Please choose at least one) * Who can we leave a message with?
8. Are you a student? * 9. Are you employed? * 10. What is your source of income? * 11. What are your hobbies and interests? Are there any accomplishments you are proud of? * 12. What do you feel are some areas of strength for you? * 13. Describe your current living situation. * Do you have any pets? * Do you have any dependents? * 14. Threshold Housing Society offers housing, support services and life-skills programming (ie: cooking classes, outdoor activities, workshops, etc.). What are you most in need of? * 15. Describe your relationship with your family. * 16. Physical and Mental Health Diagnoses: * 17. List your current medications and dosages. Who is your prescribing doctor? 18. Do you have any accessibility needs? * If yes, please describe. 19. Do you have any past or present legal charges? * If yes, please describe. 20. List any potential safety concerns: * 21. What do you feel are some challenges for you? *
eg: social skills, substance use, mental health diagnosis, physical challenges, life skills.
22. Do you know anyone currently accessing our program? * If yes, what is your relationship to them? 23. Have you applied to our program before? * If yes, when? References
Please provide two references who can speak to your character, including mental health and current living situation. The references would preferably be: a) professional counsellor, social worker, outreach worker, school counsellor, teacher, etc., b) a family reference; c) an employer or co-worker.
Reference #1: *
Reference #2: *
Release of Information *
Please note, this Release of Information will remain active for one year from the date submitted.
Is there any other information you would like to share to help us get to know you? Thank you!
We will be in contact with you soon.
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