"
*
" indicates required fields
Name
*
First
Last
Email
Phone
*
Source of Income
*
Date of Birth
*
MM slash DD slash YYYY
Residency
*
Canadian Citizen
Permanent Resident
Other
Do you identify as First Nations, Metis, or Inuit?
*
No
First Nations
Metis
Inuit
Do you identify as a man?
*
Yes
No
Other
Have you completed a medical detox program?
*
Yes
No
Other
if you completed a medical detox program, where was the medical detox program?
Have you completed a residential or structured in-patient or outpatient treatment program?
*
Yes
No
Other
Do you have a minimum of 60-90 days continuous abstinence from alcohol and non-prescribed substances?
*
Yes
No
Other
Are you currently without a fixed address?
*
Yes
No
Other
Are you willing to maintain abstinence, engage in recovery goals, and adhere to house rules?
*
Yes
No
Other
Are you able to live independently with minimal support?
*
Yes
No
Other
Are you willing to work or volunteer within 6 months of entering the program?
*
Yes
No
Other
Do you have an active Supportive Housing Registry Application?
*
Yes
No
Other
Are you currently in treatment or accessing withdrawal services?
*
Yes
No
Other
Have you lived or do you live in supportive housing?
*
Yes
No
Other
Have you or are you staying in an emergency shelter?
*
Yes
No
Other
Tell us a bit about yourself
*
Consent
*
I agree to the release of information
- To BC Housing and Cool Aid sharing my information with supportive housing providers, treatment centres, health authorities, shelter providers, outreach providers, and/or other organizations partnering with BC Housing to coordinate access to Cool Aid Recovery Housing.
- To supportive housing providers, recovery partners, health authorities, shelter providers, and/or outreach providers who are directly involved in finding suitable housing for me to make any necessary inquiries to verify the information given in this application; and, for any person, corporation or social agency to release any necessary information to the assessment of my eligibility for supportive housing.
- To members of the Supportive Housing Registry to exchange information with my Authorized Contact(s) in order to maintain and update my application.