"
*
" 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 below
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.