Applicant Form

    Your Name

    Your Email

    Your Phone

    Date of Birth

    Day

    Month

    Year

    Current Address

    Is your current address:

    Who do you live with in your current residence? Include their names and relationship to you.

    Previous addresses for the last three years? Include addresses and length of time at each address.

    Have you ever been a tenant of Winnipeg Regional Housing Authority?

    If yes, please indicate when, where and the reasons for moving.

    Have you ever applied to the Alpha House program before?

    If yes, what year?

    Day

    Month

    Year

    What is your ethnic background or heritage?

    What languages do you speak?

    Do you need a translator?

    Please provide some information about your children. Include their names, gender, birthdates, grade, and location.

    Do your children have any serious health/medical problems?

    Do you have any serious health/medical problems?

    Are you pregnant?

    What are your current sources of income?

    Will this income change within the next 2 months?

    Please explain:

    If employed or in training outside the home, please provide the following:

    Employer’s name and address:

    Employer’s phone number:

    Employer’s hours and type of work:

    What is your educational background?

    Degree, diploma, or trade:

    Please provide some information on the abusive partner:

    Name:

    Birthdate:

    Day

    Month

    Year

    Ethnic Background:

    Address:

    Most recent violence:

    When did the last violent incident occur?

    What type of violence occurred?

    Was a weapon used in any of the assaults?

    What type of weapon?

    How often were you abused?

    Are you in immediate danger at this time?

    History of violence:

    Have you been involved in more than one abusive relationship?

    If yes, please tell us about these relationships. Include Name, Length of Relationship, Type of Abuse

    Were you abused as a child?

    If yes, was the abuse:

    Have your children ever been abused?

    Please describe what happened:

    Are your children in immediate danger?

    Are Child & Family Services involved?

    Do you have a restraining order?

    Please describe:

    Have you ever left your partner because of abuse?

    If yes, please indicate when:

    Day

    Month

    Year

    Where did you stay?

    Length of time away?

    Please provide us with some information about you or your family’s contact with any helping agencies, including counselling, groups, social services, police, legal, or others. List the organization, person seen, dates, and purpose.

    Do you have a history of alcohol or other drug abuse?

    If yes, please describe:

    How do you think the Alpha House program can help you and your children?

    Do you have any questions or concerns about Alpha House? Please list them below:

    I HEREBY AGREE TO THE EXCHANGE OF INFORMATION BETWEEN THE REFERRING AGENCY AND ALPHA HOUSE RELATING TO THE PROCESSING OF THIS APPLICATION.