Referral Type *

Self

Agency / School

Name of Applicant *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

What gender do you identify as? *

Man (inc. trans man)

Women (inc. trans woman)

Non-Binary

Prefer not to say

Prefer to self-describe

Do identify with the gender you were assigned at birth? *

Yes

No

Prefer not to say

Have you used the Nightstop program before? *

Yes

No

What is your preferred method of contact?

Phone

Email

Is this your first time experiencing homelessness? *

Yes

Did you feel safe there? *

Yes

No

Have you slept rough before? Meaning, sleeping in the open air (e.g. streets, doorways) or in buildings not designed to be lived in (e.g. parking lots, stairwells, sheds) *

Yes

No

If yes, approximately how many nights? *

Less than 7

7-14

14-30

More than 30

What is your last know address? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What type of accommodation was that? *

Family

Friend

Supported Accommodation

Other

Do you have people or organizations that are a part of your support system? *

Yes

No

Do you require an interpreter? *

Yes

No

Do you consider yourself to have a disability? *

(Including Mobility)

Yes

No

Please Check all that Apply: *

In work

In Training

Looking to Study

Studying / In Education

Looking for Work

Looking for Training

Reference's Name

First Name

Last Name

Reference's Phone *

(###)

###

####

Reference's Name

First Name

Last Name

Reference's Phone *

(###)

###

####

What is your sexuality? *

Lesbian/Gay

Bisexual 

Heterosexual 

Prefer not to say 

Prefer to self-describe

What is your ethnicity?

Caucasian

Black

Hispanic

Middle Eastern

Central Asian

​Eastern Asian

First Nations

Metis

African

Afro-Caribbean 

Prefer not to say

What is your religion? *

None  

Buddhist  

Christian  

Hindu  

Jewish

Muslim  

Sikh  

Prefer not to say