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Addiction and Mental Health Services - KFLA
Kingston/Napanee  Ontario

Phone: (613) 544-1356
Fax: (613) 544-2346
Housing Application
Date: 2025-04-18 23:58
Hide/ShowHousing Application

Please complete all sections of the form when possible; for example, even if answer is 'no' for income sources, please select NO. Do not leave blank.

Addiction & Mental Health Services - KFLA Support Team (If Applicable):
Addiction & Mental Health Services - KFLA Support Worker:
Hide/ShowApplicant Contact Information
First Name:
Last Name:
Alias (AKA):
Telephone #:
Alternate Phone:
Email:
Street Address:
Apt #:
Entry Code:
City:
Province:
Postal Code:
Nearest Intersection:
Are you currently homeless?
How many months have you stayed in an emergency shelter in the past year?
Are you currently at risk of becoming homeless or marginally housed?
If no fixed Address, Please provide possible location where person might be found?
Hide/ShowAlternate Contact Information

If you do not have a phone or are otherwise hard to reach, is there someone with whom you are in regular contact that we can call in order to reach you?

 

Name:
Phone:
Relationship:
Organization:
Can a message be left at the number provided?
Hide/ShowApplication Form - General Information
Date of Birth:
Select Date Clear Date
Gender:
Do you have an Ontario Health Card:
Yes
No
Don't Know
Ontario Health Card Number:
Do you speak English?
Yes
No
Don't Know
What is your first Language?
What if your preferred Language?
Do you need an interpreter?
What is your primary source of income?
If Other, please specify:
What is your secondary source of income?
If Other, please specify:
Please enter your total monthly income($):
Please enter the total value of your assets (See Appendix for definition of assets):
(This includes RRSP's TSFAs...)
If you have applied for one of the above sources but are not yet receiving it, please provide the details:
(Please provide as much information as possible)
Do you have a trustee or Power of Attorney for finances?
Yes
No
Don't Know
Name:
Phone Number:
Email:
Who do you presently live with?
What type of housing do you presently live in?
If Other, please specify:
(Please provide as much information as possible)
Hide/ShowHealth Information
Is this your first experience with mental illness?
Yes
No
Unknown
How long have you been experiencing mental health difficulties? (In Years):
Have you been formally diagnosed with a mental illness?
Yes
No
Unknown
If yes, what is/was the primary diagnosis?
(Please provide as much information as possible)
Secondary diagnosis?
(Please provide as much information as possible)
Additional diagnosis:
(Please provide as much information as possible)
Have you ever experienced psychosis?
Yes
No
Unknown
If you are struggling with any other mental health issue, please explain/state:
(Please provide as much information as possible)
Have you been to hospital due to mental health issues in the last two years?
(Emergency Room visits and/or in-patient stays)
Yes
No
Unknown
Please provide an estimate of the total number of days that you have spend in hospital in-patient units, due to mental health issues, within the past two years (estimate in days):
Please list the hospitals you have been in and the dates of your visit:
Are you currently in the hospital due to mental health issues?
If yes, are you currently designated ALC(alternative level of care)?
Are you currently on a Community Treatment Order (CTO)?
Other Illness/Disability
Do you have any other illnesses/disability?
Concurrent Disorders (Substance use and mental illness)?
Yes
No
Unknown
Dual Diagnosis (Developmental disability and mental illness)?
Yes
No
Unknown
Neurological (Head/brain injury, epilepsy, Parkinson's cognitive disorders etc)?
Yes
No
Unknown
Other chronic illness and/or physical disabilities (eg hypertension, diabetes, allergies)?
Yes
No
Unknown
If yes to any of the above, please describe:
(Please provide as much information as possible)
If you are struggling with any intellectual disability please explain/state:
(Please provide as much information as possible)
Medical Contacts
Do you have a psychiatrist?
If Yes, Name:
Address:
Telephone #:
Fax #:
Email:
Do you have a physician:
If yes, Name:
Address:
Telephone #:
Fax #:
Email:
Hide/Show Existing Agency Support (dummy_group)
Delete

Please fill out the below for each service provider with whom you are currently working 

Are you currently working with any other service providers?
Agency:
If not listed, Agency:
Program Name:
Contact Name:
Services Received:
Phone:
Email:
Hide/Show Existing Agency Support (1)
Delete

Please fill out the below for each service provider with whom you are currently working 

Are you currently working with any other service providers?
Agency:
If not listed, Agency:
Program Name:
Contact Name:
Services Received:
Phone:
Email:
Add Section Add Existing Agency Support
Hide/ShowInformal Supports
Please Describe the informal supports in you life and how satisfied you are with each of these supports:
(Family, friends, faith, community, cultural groups/community, other community supports)
(1)
new button
(dummy_field)
Hide/ShowSupport Needs

In order to match your needs to an appropriate housing vacancy, please indicate what level of support you would need from the Supportive Housing Provider in the following areas:
Please note: your selections in this chart will inform AMHS-KFLA as to which housing options would be appropriate for you and will affect which vacancies you are contacted for. If you need assistance or further information, please contact Coordinated Access at 613-544-1356.

What extra supports might you need?

Would you like support with any of the following?

Housing
Housing Needs:
Looking after your home:
Social Support
Developing Positive Relationships:
Meeting new people/social and peer support:
Health and Wellness
Managing specific symptoms:
Diabetes Education:
Self-managing medication:
None
Some
A Lot
Dealing with drug and alcohol use:
Wellness recovery action planning:
Physical health and education:
Getting to appointments:
Self-care:
None
Some
A Lot
Food and Nutrition
Nutrition and diet information:
Shopping:
Assistance with meal preparation:
None
Some
A Lot
Do you need meals provided?
Finances
Financial Responsibilities:
Legal
Legal Issues:
Self-advocacy- knowing your rights:
Maintaining Safety
Avoiding unsafe situations:
Avoiding crisis and dealing with anger:
Employment and Education
Understanding English, Reading, Writing, Literacy Skills:
Improving employability and career possibilities:
Education/Training:
Daily Activities
Using transportation/buses:
Adding structure to your day:
Developing daily living skills:
Other Areas:
(Please provide as much information as possible)
Hide/ShowSafety Risks

We ask the following questions to determine if there are any safety or risk issues of which we should be aware. Answering any of the questions below will NOT exclude you from service. We know these are sensitive questions and we appreciate you answering them. If you have any recent (i.e., past three years) history of the following, please comment (e.g., when, how many incidents, how severe, outcome)

If you struggle with any of the items listed, please indicate how long it has been since the last incident
Alcohol use that causes you harm:
No
6 Months
6m - 1 Yr
1-5 Yrs
Thought of Suicide:
No
6 Months
6m - 1 Yr
1-5 Yrs
Suicide Attempts:
No
6 Months
6m - 1 Yr
1-5 Yrs
Self Harm:
No
6 Months
6m - 1 Yr
1-5 Yrs
Drug use that caused harm to you:
No
6 Months
6m - 1 Yr
1-5 Yrs
Lack of attention while smoking:
No
6 Months
6m - 1 Yr
1-5 Yrs
Mishandling fire/fire setting:
No
6 Months
6m - 1 Yr
1-5 Yrs
Assault by you - Physical:
No
6 Months
6m - 1 Yr
1-5 Yrs
Assault by you - Sexual:
No
6 Months
6m - 1 Yr
1-5 Yrs
Assault by you - Verbal:
No
6 Months
6m - 1 Yr
1-5 Yrs
Problems with Anger Management:
No
6 Months
6m - 1 Yr
1-5 Yrs
Inappropriate Sexual Behaviour:
No
6 Months
6m - 1 Yr
1-5 Yrs
Destroying/Abuse of Property:
No
6 Months
6m - 1 Yr
1-5 Yrs
Gambling:
No
6 Months
6m - 1 Yr
1-5 Yrs
Issues with Collecting things:
No
6 Months
6m - 1 Yr
1-5 Yrs
Problems with Violence:
No
6 Months
6m - 1 Yr
1-5 Yrs
History of Homelessness/Risk of Homelessness:
No
6 Months
6m - 1 Yr
1-5 Yrs
Accidently Started Fire in your unit:
No
6 Months
6m - 1 Yr
1-5 Yrs
Rate the Cleanliness of your Apartment:
0
1
2
3
4
5
Have you had challenges with past landlords?
How often do you have overnight guests?
None
Once a Month
Once a Week
More
Comments or Other Challenges:
Hide/ShowLegal Involvement
Are you currently, or have you in the past been involved with the criminal justice system?
If yes, please state the number of contacts with the justice system in the previous year:
Please complete the following if you have current legal involvement (Check all that apply)
Pre-Charge:
Pre-Charge Diversion
Court Diversion
Pre-Trial:
Awaiting Fitness Assessment
Awaiting Trail (With or Without Bail)
Awaiting Criminal Responsibility Assessment (NCR)
In Community on own Recognizance
Unfit to Stand Trail
Custody Status:
ORB Detained - Community Access
ORB Conditional Discharge
On Parole
On Probation
Incarcerated
Outcomes:
Charges Withdrawn
Restraining Order
NCR
Conditional Sentence
Awaiting Sentence
Suspended Sentence
Stay of Proceedings
Peace Bond
Conditional Discharge
Other:
No Legal Problem
Other Criminal/Legal Problems
Unknown
Hide/ShowHousing Preferences
What other types of housing will you accept?
Rooming House/Shared Living in a House or Apartment
My Own Apartment
Supportive Housing Where I Participate in Groups and Programming
If Applicable, How often would you like staff onsite/visiting your unit?
24 Hours
Daily
Occasionally
If Applicable, please explain:
(Please provide as much information as possible)
Hide/Show Medical Supports Within Housing (dummy_group)
Delete
Do you require housing/support services suitable for a person with physical ability issues?
If yes, please explain:
(Please provide as much information as possible)
Are you living with diabetes or a pre-diabetic condition?
Hide/Show Medical Supports Within Housing (1)
Delete
Do you require housing/support services suitable for a person with physical ability issues?
If yes, please explain:
(Please provide as much information as possible)
Are you living with diabetes or a pre-diabetic condition?
Add Section Add Medical Supports Within Housing
Hide/Show Housing History (dummy_group)
Delete

Applicants Previous Housing References and History

Under the Residential Tenancies Act, in selecting prospective tenants, landlords may use income information, credit cards, credit references, rental history, guarantees or other similar business practices permitted under the Human Rights Code regulations.
Please list your housing history for the past three years:

Address:
Type of Housing:
Landlord/Agency Name:
Phone Number:
Date Moved in:
Select Date Clear Date
Date Moved out:
Select Date Clear Date
Reason for Leaving:
Hide/Show Housing History (1)
Delete

Applicants Previous Housing References and History

Under the Residential Tenancies Act, in selecting prospective tenants, landlords may use income information, credit cards, credit references, rental history, guarantees or other similar business practices permitted under the Human Rights Code regulations.
Please list your housing history for the past three years:

Address:
Type of Housing:
Landlord/Agency Name:
Phone Number:
Date Moved in:
Select Date Clear Date
Date Moved out:
Select Date Clear Date
Reason for Leaving:
Add Section Add Housing History
Hide/ShowSubstitute Decision Maker (SDM)

If the person filling out this form is a SDM for the applicant, then the questions in this form relate to information about the individual needing support (applicant). If you are the SDM for the applicant, please provide the following information:

Name:
Address:
Phone Number:
Email Address:
Relationship to Applicant:
Type of SDM:
The SDM herby declarers that he or she is the person authorized under the Personal Health Information Protection Act, 2004 to consent to the collection, use and disclosure of personal health information about the applicant and consent on behalf of the applicant:
Hide/ShowReferral Source/Worker/Agency - For Non Self-Referrals
Referrer's Name:
Referrer's Agency:
Title:
Telephone:
Call #:
Fax #:
Email:
Street Address:
Apt/Suite #:
City:
Province:
Postal Code:
Relationship:
Is the applicant aware of this referral?
Hide/ShowReferrer's Declaration

If a person other than the applicant or SDM is completing this application and making the referral, the referrer must complete the declaration below. Please read it carefully. Please note applications will only be accepted with the consent of the applicant or Substitute Decision Maker if there is one.

 

NOTE: There are 10 pages to this application. Please complete all answers even if the answer is no and complete all pages before submitting

To the best of my knowledge, the information contained in the application is correct:
I have discussed this application with the applicant, explained the role of the AMHS-KFLA Coordinated Access:
I have obtained the applicant's knowledge and voluntary consent to make this referral and to the collection, use and disclosure of PHI as set out in the application:
Hide/ShowConsent & Declaration for Collection, Use & Disclosure of Personal Information

Please have all household members 16 years of age read this declaration.

 

What is Personal Information?

 Personal Information includes any factual or subjective information, recorded or not, about an identifiable individual. This includes information in any form, such as:

age, name, ID numbers, income, assets, household composition, residency status, rent payment record, etc;

opinions, evaluations, comments, social status, or disciplinary actions; and

employee files, credit records, loan records, medical records, existence of a dispute between a landlord and a tenant, intentions (for example, to acquire goods or services, or change jobs).

 

Collection and Use of Your Personal Information

 Addiction & Mental Health Services - Kingston, Frontenac, Lennox and Addington (AMHS-KFLA) will collect, retain, and use the personal information provided by you in this form and its attachments for the following purposes:

considering your application for tenancy;

verifying the information that you have provided in your application for tenancy, and its attachments;

calculating your rent;

meeting legal and regulatory requirements arising out of or relating to your tenancy;

for the use of AMHS-KFLA's auditor to verify our financial records;

for the purpose of contacting necessary services or your next-of-kin in case of emergency;

 

Disclosure of Your Personal Information

 AMHS-KFLA will disclose the personal information provided by you in this form to the following parties for the purposes described above:

To any social agency providing any form of assistance to you, or other government subsidy under the Ontario Works Act, 1997, the Ontario Disability Support Program Act, 1997 or the Day Nurseries Act, or any government department responsible for social housing programs under the Social Housing Reform Act, or Frontenac Community Mental Health Services' housing service agreement with the Ministry of Health and Long Term Care;

To the Government of Canada, a department, ministry or agency of it, without further notice to you if the information is necessary for the purpose of administering or enforcing the Income Tax Act (Canada) or the Immigration Act;

To relevant agencies or next of kin in case of emergency;

To credit bureaus and other businesses that provide credit or rental history information about you;

To a third party in connection with the potential or actual sale, reorganization, merger, consolidation or disposition of the business of AMHS-KFLA and;

To provide rental information to the MOHLTC for the purpose of rent subsidy.

Reviewed with Client:
Date:
Select Date Clear Date
Client Provided with Tenant Annual Contract Requirement (pg 9):
Date:
Hide/ShowTenant Annual Contract Requirement

Please Retain this Sheet for your Records

Date Application was Submitted:
Select Date Clear Date
 

If staff are completing this application - please give this form to the applicant
 
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