Interview will be conducted with residence to determine suitability following referral form submission.

Client Eligibility:

All clients must meet the following criteria:

• Be 18 years of age or older.
• The applicant must be a resident of the Rainy River District.
• Be substance free before entering HOPE Transitional Housing.
• Be willing to actively participate in HOPE Transitional Housing Programs.
• Be medically and psychiatrically stable.
• Require a level of recovery service and/or support away from their usual living situation.
• Be able to pay the program fee (maximum social assistance-shelter allowance rate) and cover the cost of personal needs

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Client Information

Name *

First

Middle

Last

Gender

Date of Birth

Phone

Email

Referral Details

Self-referrals do not need to complete

Date

Referring Agency

Contact Name

Email

Phone

Fax

Income Source

Amount

Upload a copy of one of the following

• 60-day bank statement
• Verification of Employment – 3 months
• Verification of OW/ODSP
• Notice of Assessment for most recent year

File Upload

Click or drag a file to this area to upload.

Client/Authorized Representative Signature *

Clear Signature

Date Signed *

Submit