Brantford Native Housing
Residential Support/
Addiction Treatment Program
Application Package
Ojistoh House or Karahkwa House
318 Colborne Street East
Brantford, ON
N3S 3M9
(519) 753-5408 x 235 – T
(519) 756-1764 – F
Brantford Native Housing
Addiction Residential Support Program Application Process
Background
The Residential Support Addiction Treatment Program is offered through Brantford
Native Housing. This program is offered to Aboriginal men (Karahkwa House) and
women (Ojistoh House) (18 +) who are in recovery from drug and/or alcohol use.
Residents can stay in the Residential Support Addiction Treatment Program for up to
one (1) year and receive up to two (2) years of supports while residing in the
community. Residents must have four months of abstinence from all alcohol and illicit
drugs and have abstinence as your goal to qualify for the program.
Brantford Native Housing provides addiction programming that incorporates both
Aboriginal specific health and healing programming as well as cognitive behavioural and
biopsychosocial addiction treatment models.
Residents will be expected to maintain abstinence from all alcohol and recreational
(mood altering) drugs while residing in the Residential Support Addiction Treatment
Program and participate in programming.
Application Process
Brantford Native Housing Residential Support Addiction Treatment Program is
transitional housing. It is expected that Applicants have attended an in-patient
residential treatment program or received extensive outpatient treatment support. We
require all incoming applications to be completed by a community service
agency/addiction treatment program. Self referrals also accepted if references
(agencies you are/have worked with) provided. Completed applications can be faxed
to:
Transitional Support Worker – 519-756-1764
Once we receive the completed application forms, a Brantford Native Housing staff
person will contact the Applicant within one (1) week to schedule an intake interview to
assist in determining eligibility and obtain any additional necessary information for
review of the application.
Eligibility Criteria
1. At least 50% of the family (female Applicants bringing children) must be of
Aboriginal ancestry. Male Applicants must be of Aboriginal ancestry;
2. Applicant must be in need of housing due to homelessness or at-risk of
homelessness (i.e., living in a shelter, temporarily staying with family or friends,
etc.);
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3. The Applicant must be 18 years of age or older;
4. The Applicant must be eligible for Ontario Works, ODSP or other income
programs, if not working or attending school or a training course;
5. Committed to paying service fees;
6. Committed to the aftercare program (if coming from a treatment program) and/or
full abstinence from drugs/alcohol and participate in our treatment programming,
which includes individual counselling, group counselling and attendance in a peer
support group;
7. Committed to connecting with community resources and moving toward an
independent and healthy lifestyle; and
8. Applicants must agree to sign our Consent to Obtain Information form with the
referring community service agency and other service providers the Applicant is
working with.
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Residential Support / Addiction Program
Application Form

Ojistoh House (Female)

Karahkwa House (Male)
APPLICANT NAME:_____________________________________________________
Date of Birth:___________________________________________________________
Aboriginal Ancestry:
First Nations – Status

First Nations – Non-status 
Métis 
Inuit 
Applicant Band and Number:_______________________________________________
Applicant Address:_______________________________________________________
Telephone/Fax:_________________________________________________________
Email:_________________________________________________________________
APPLICANT DEPENDENTS:
1. Name:______________________________________
DOB:__________ Age:__
Aboriginal Ancestry:___________________________
Gender:_______________
2. Name:______________________________________
DOB:__________ Age:__
Aboriginal Ancestry:___________________________
Gender:_______________
3. Name:______________________________________
DOB:__________ Age:__
Aboriginal Ancestry:___________________________
Gender:_______________
4. Name:______________________________________
DOB:__________ Age:__
Aboriginal Ancestry:___________________________
Gender:_______________
5. Name:______________________________________
DOB:__________ Age:__
Aboriginal Ancestry:___________________________
Gender:_______________
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APPLICANT INCOME:
1. What is the Applicant’s last source of income?______________________________
2. Does the Applicant receive child support payments?_________________________
3. Does the Applicant understand that she/he is required to pay service fees to stay in
the Addiction Residential Support Program?
 Yes
 No
REFERRING AGENCY INFORMATION:
Name of Agency:________________________________________________________
Name/Position:_________________________________________________________
Address:_______________________________________________________________
Telephone/Fax/Email:____________________________________________________
1. Is the Applicant able to complete daily living chores?_________________________
2. Does the Applicant have any disabilities?__________________________________
APPLICANT INFORMATION:
1. Does the Applicant have any children that are not in their care and will not be staying
with the Applicant?
 Yes
 No
2. Where is the Applicant presently living?
 Shelter
 Family/friends
 Hotel/Motel
 Other___________________
How long ?__________________________________________________________
3. Are there any safety issues/concerns regarding current or past intimate
relationships?  Yes
 No
 Restraining order  Peace bonds  Custody orders  CAS conditions
 Other ____________________________________________________________
If yes, please explain:
______________________________________________________________________
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4. Is the Applicant on Probation or Parole?  Yes
 No
If yes, who is the Probation/Parole Officer?____________________________________
Contact info:____________________________________________________________
5. What other agencies/service providers is the Applicant currently working with?
 Ontario Works  C.A.S  Probation & Parole  Mental Health Supports
 Counselling  Legal Services  Public Health Services  Training Program
 Employment Services  Other, please explain
__________
________________
6. History of Drug/Alcohol Use:
Drug/Alcohol used
Age when 1st used
Age when last used
7. History of Drug/Alcohol Treatment:
Has the Applicant been to Detox?
 No  Yes - Date_______________________
Has the Applicant recently attended an Addiction Treatment Program?  No
 Yes, where and when?_________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Does the Applicant have an Aftercare Plan?  No  Yes (attach copy)
Does the Applicant have a Sponsor?  No  Yes
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8. What wellness steps has the Applicant taken?
 Support System
 Therapy/Counselling
 AA
 NA
 Anger Management
 Group Therapy
 Cultural Activities
 Other_________________________________________
9.
Is the Applicant on the Methadone program?
 Yes
 No
If yes, where does the Applicant access the meds and who manages their participation?
______________________________________________________________________
Current Dose:__________________________________________________________
Length of time in Methadone Program and history of dose:
______________________________________________________________________
10.
What other goals will the Applicant be working on not related to substance use?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
11.
Who does the Applicant include as support during crisis?
Name:
Relationship
Contact Information:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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12. Emergency Contact Persons:
Name:
Relationship:
Contact Information:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
APPLICANT EDUCATION:
 Some High School  High School Grad  GED Some College
 College Grad  Some University  University Grad  Technical/trade certified
 Training ____________________________________________________________
APPLICANT WORK HISTORY:
Is the Applicant currently employed?  Yes
 No
Employer: _____________________________________________________________
Address:_______________________________________________________________
Telephone/Fax:_________________________________________________________
Position: ______________________________________________________________
Work hours:_______________________ Salary/Wage per hour__________________
Does the Applicant have an up-to-date resume?
 Yes
 No
Does the Applicant want to work?
 Yes
 No
HEALTH INFORMATION:
1. Are there acute medical complications that may require referrals to emergency or
hospital for immediate medical assessment?
 Yes ____________________________________________________________
 No
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2. When did the Applicant last see a physician? ______________________________
Doctor:________________________________ Phone #: _____________________
Address: ___________________________________________________________
3. Does the Applicant have any life threatening allergies?
 Food Environment
 Medicine If yes, please explain:
___________________________________________________________________
4. Does the Applicant carry an Epipen for allergies?
 Yes
 No
5. Is the Applicant currently in any type of treatment or counselling for emotional or
mental health problems?
 Yes, where?_______________________________________________________
 No
6. Was the Applicant hospitalized in the last year? If yes, for what reason.
 Yes ____________________________________________________________
 No
7. List all current medications, dose and the reason for taking it.
Medication
Dose
Reason for Taking
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
8. Health Screening: Check all that apply.
 Diabetes
 High/Low Blood pressure
 Epilepsy or seizures
 Liver disease
 Cancer
 Kidney disease
 Eating disorders
 Asthma
 Heart disease
 Menstrual/menopausal difficulties
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 Pregnancy
 Sexually transmitted disease
 Pancreatitis
 Lice/scabies
 Physical or sexual abuse
 Stomach problems
 Emotional/verbal abuse
 Tuberculosis
 Recent untreated injury
 Head injury
 Tuberculosis ~ TB
 Hepatitis A B or C
Please add any additional information that will assist our understanding of the
Applicant’s needs.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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Brantford Native Housing
Addiction Treatment Program
Brantford Native Housing provides a supportive residential addiction treatment program
and an outpatient structured relapse prevention group and limited short-term individual
counselling for individuals concerned about alcohol and drugs. This program is
designed to help individuals review their lifestyle, identify changes they would like to
make, and help them develop the necessary skills to make those changes. Referrals to
residential treatment programs or community programs are provided. Consultation is
also available for family members, friends or professionals who are concerned about
someone else’s use of alcohol or drugs.
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Services are provided free of charge.
All sessions are by appointment only.
During scheduled group times we are unable to provide immediate appointments.
If you are in crisis please call:
Nova Vita (Emergency Shelter – 24 hour crisis line)
519-752-4357
St. Leonard’s (Community Service – 24 hour crisis line) 519-759-7188
or 1-866-811-7188
Clients arriving at the agency under the influence of drugs or alcohol will have
their appointment rescheduled.
All services are confidential within the agency, with five exceptions listed below:
While attending services with Brantford Native Housing, what you discuss with your
counsellor and group leaders is private and confidential to the agency. Your
counsellor/group leader cannot and will not freely share any information about you to
others outside the agency. This means that you must give permission in writing in order
for us to release information about you to anyone else.
There are exceptions, required by law, where information may be given out
without your consent. These include the following:
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Suspected child abuse or neglect will be reported to the Children’s Aid Society of
Brant;
When someone is intending on harming him or herself (i.e. suicidal) or someone
else (i.e. homicidal);
A subpoena or summons is served by the courts;
When a person arrives under the influence of alcohol or drugs and insists on
driving, the Brantford Police Department will be notified if alternative
arrangements are refused; and
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•
Cases of medical emergencies, the ambulance/medical personnel will be
provided with your name and emergency contact information.
Under the Personal Health Information Protection Act (PHIPA) it is important for you to
understand how your personal health information is protected and how it is used.
All workers at Brantford Native Housing are aware of the sensitive nature of your health
information and have received training in the Acts and are sworn to an Oath of
Confidentiality. If you are concerned about how your personal health information is
collected, used or disclosed, you may file a complaint against Brantford Native Housing
or an individual, through the Information and Privacy Commissioner of Ontario.
At Brantford Native Housing, an assigned Intake Worker or designated Program Worker
will collect your information. From time to time, you may be accessing more than one
program or service. This consent form will serve for all Brantford Native Housing
programs you are currently accessing. Your original consent will be kept in your primary
program file (the service you have the most contact with).
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only necessary information is collected about you;
your information is only shared by written consent (with the noted exceptions);
and
storage, retention, and destruction of your personal health information complies
with our file maintenance policy, legislation and privacy protection protocols.
NOTE:
From time to time this information may be used to do studies/ research/ reports on issues
specific to the health of urban Aboriginal peoples and for the purpose of procuring additional
funding. At no time will any identifiable information be processed for such use.
By signing the consent section of this Client Consent Form, you have agreed that you have
given your informed consent to the collection, use and/or disclosure of your personal and health
information for the purposes listed. Should a new purpose arise, we shall seek your approval
first.
You may withdraw your consent at any time for the collection, use, or disclosure of your
personal health information by providing notice to your primary worker within Brantford Native
Housing. You also can place a condition or restriction on your consent, in that you may choose
to restrict all or part of your health information from being shared. You also have the right to
access your own personal health information, through a written request to the Manager,
Community Programs.
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CLIENT CONSENT
1. I have reviewed the preceding information and had it explained to me and /or the
person who is my legal guardian; or has my power of attorney, where necessary;
on how Brantford Native Housing will use my personal information and personal
health information.
2. I am also aware of the steps taken by Brantford Native Housing to protect my
information, when it is collected, used or disclosed, as well as how it will be
stored and destroyed.
3. I agree that Brantford Native Housing can collect, use and disclose personal and
personal health information about myself, or for my children under the age of 12
as their legal guardian; or I have power of attorney for their health; or they are my
child/children as set out in the above information.
___________________________________________
Applicant Signature
_____________________
Date
___________________________________________
Witness
_____________________
Date
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