Application for Place of Refuge Housing Program

At Place of Refuge, our team combines professional expertise with genuine compassion to support each resident’s wellness journey. With diverse backgrounds in leadership, counselling, life-skills and community-based work, the staff at Place of Refuge foster a safe and respectful environment where the residents can heal, grow, and take steps toward lasting change in their lives.

Apply for Housing

Applicant Data

Applicant Name:

Age:

D.O.B:

Your Email:

Applicants must:

Have a demonstrated commitment to recovery for at least three months (or as assessed by staff)
Be motivated and ready to implement a personal recovery plan with monthly reviews that includes a:
- concrete and detailed action plan for employment or education that you will implement while in the structured Transition housing program
- recovery maintenance and relapse prevention plan
- financial management plan
- social and leisure time action plan
- plan to address your prioritized recovery needs
Have a demonstrated commitment to abstinence
Be stable enough to self-organize successfully in the routines of healthy daily living

How do you apply to access the Place of Refuge Transition Housing Program?

Substance use and mental health professionals can refer you to the program
Self-referrals are also welcome
Complete the application form on the next page
Contact Reive Doig at the Place of Refuge Housing Program Admissions Office at 778-885-5463
Email: [email protected]

Admissions
Reive Doig – Support Staff
Phone: 778-885-5463
Fax: 1 (778) 743-8173
Email: [email protected]

Applicant Data

PHN:

S.I.N:

Tel:

Length of abstinence as of today:

Clean Date:

Are you an IV drug user?

Yes

Current Program or Address where you are now:

A&D Counsellor or Case Worker:

Tel:

How did applicant hear about Place of Refuge Housing Program?

Substance Use History

Substance used	Route of Administration	Age first used	How long substance used?	Is it the Primary Drug of Choice?

Health

Is there a physical health problem you are most concerned about right now?

Current Medications

Medication Name:	Dosage:	How long have you been taking this medication?	Administration times per day:

I am taking these medications regularly

Yes

If not, why not?

Diagnosed Mental Health Conditions

Diagnosis:	At what age:	Diagnosed by:	Other:

Current Medications

Medication Name:	Dosage:	How long have you been taking this medication?	Administration times per day:

I am taking these medications regularly

Yes

If not, why not?

Health – Suicide Risk

Have you ever felt suicidal?

Yes

How recently?

Have you ever tried?

Yes

How recently?

By what method?

Were you hospitalized?

Yes

How long was your stay in hospital?

Were you seen by a psychiatrist while you were in hospital?

Yes

Name:

Medical Contacts

Physician Name:

Physician Telephone:

Specialist Name:

Specialist Telephone:

Psychiatrist Name:

Psychiatrist Telephone:

Case Manager Name:

Case Manager Telephone:

Other Support Person Name:

Other Support Person Telephone:

Treatment History

Dates of Treatment:	Type:	Facility Name:	Completed or incomplete (If incomplete, why?)

Clean Time History (Other Periods of Abstinence)

From:	To:	What happened that started your substance use again?

Recovery Action Planning

What plans have you made to support your recovery in the Transition Housing Program? Which step are you working on now? Are you willing to participate in individual and group counselling? List the names of people (and your relationship with them) who would be willing to support you in your recovery:

How many community-based meetings do you attend per week?

Do you have an outpatient drug and alcohol counselor that you are seeing regularly?

List the names of people who are willing to support you in your wellness plan?

Name:	Relationships to you:

In order of importance to you, make a list of your needs that you feel you need to prioritize in order to enjoy a healthy wellness-based lifestyle:

Relapse Prevention Action Planning

The Place of Refuge Housing program has a special focus on relapse prevention skills. Relapse can be defined as a return to former self-defeating thoughts, feelings and behaviors which can result in a return to substance misuse. Developing a relapse prevention action plan will help you firm up your personal commitment to a clean and sober lifestyle and can serve as a starting point to measure your progress in the process of recovery. Putting your plan into action can be a vital factor in reducing the risk of relapse. Please describe your relapse prevention plan:

What are your high-risk situations?

What are your plans to manage each of your personal high-risk situations?

How do you plan to cope with stress that comes with new challenges and changes in lifestyle?

Who are the key people you have chosen to support you in your relapse prevention planning? What instructions have you given them about their roles as key supports in your relapse prevention planning?

Criminal Justice Involvement History

Do you have a criminal record?

Yes

What are your previous charges?

Charged with:	When:

Are you facing any current charges?

Yes

What are the charges?

Are you on probation/parole currently?

Probation

Parole

If you're on parole, what are the conditions of your order?

Do you have upcoming court dates?

Yes

Date:

Probation/Parole Officer Name:

Contact Number:

Employment Action Planning

How long have you been unemployed for?

1 to 6 months

7 to 12 months

13 to 24 months

more than 2 years

What kind of work do you do?

What kind of work would you like to do?

Do you need help with education, skills, or training to find and keep employment?

Yes

What are the main employment action plan goals you want to accomplish?

What steps do you plan to take to reach these goals?

Education Action Planning

What are the main educational action plan goals you want to accomplish?

What education, skills and/or training do you need?

What steps do you plan to take to reach these goals?

Who are the key support people who can help you with your educational action plan?

Health and Physical Fitness Action Planning

What needs have you identified in the area of health and physical fitness?

What goals would you like to set for yourself in this area?

What steps do you plan to take to meet these goals?

Healthy Social Life/Leisure Planning

What do you like to do in your free time?

What social and leisure or recreational activities do you plan to participate in?

What steps do you plan to take to meet these goals?

Healthy Life/Work Balance Planning

What is your plan to achieve a healthy balance between work and education and your personal life goals?

What steps do you need to take to achieve a balance that’s right for you?

What are the key parts of your stress management plan?

Sources of Income

Employment

Amount per month

Comments

Employment Insurance

Amount per month

Comments

Employer (Union, EAP)

Amount per month

Comments

Income Assistance (Basic)

Amount per month

Comments

Income Assistance (PWD)

Amount per month

Comments

Income Assistance (PPMB)

Amount per month

Comments

Self-pay

Amount per month

Comments

CPP

Other Pension

Amount per month

Comments

Other

Amount per month

Comments

Family and Friends Action Planning

Are family and friends supportive?

Yes

Do you have a significant other who is supportive of your recovery?

Yes

Do you have children?

Yes

Are you hoping to reunite with your family?

Yes

How do you plan to improve your social network for your recovery?

Hopes and Dreams

What are your hopes and dreams that you would like to achieve while in the Transition housing program?