Daybreak Housing
393 Picadilly Ave
Ottawa, Ont.
K1Y 0H3

Tel: 613-236-8070
Fax: 613-236-9083

Email Us



Residency

What residents say

"Daybreak was the light at the end of my tunnel. I finally feel understood, not alone."

"Daybreak gave me back the strength and confidence to move on with my life again."

"I have learned to trust in my ability to succeed and build a better future for myself."

"I now have an excellent job, a great place to live and I am back in recovery. I may never have made it without Daybreak."


Applying for Residency

To apply for residency, please call 613-236-8070, extension 221 to have a form mailed to you, fill in the application form below or download an applicationform.

(Note: to download an application form, you may first need to download the free Adobe Acrobat Reader)

After Daybreak receives a completed form, applicants will be contacted to arrange an interview at Daybreak's office.

Note: that processing of an application will include reference checks

Residency Application Form
GENERAL INFORMATION
* First Name
* Last Name
Phone
* Email
Address
How long have you been at this address?
Reasons for leaving this address?
What was your previous address?
How long have you been at this address?
Reasons for leaving this address?
Have you lived in a Daybreak home? no yes
from to
GenderMale Female
Date of birth dd  mm  yyyy   Age
First choice language spoken Second
IN CASE OF EMERGENCY CONTACT
Name
Relationship to applicant
Address
Home Phone Business Phone
PRESENT SITUATION
At the present time I live with friends family a group alone
My current dwelling is
house rooming house supported group home street
shelter recovery home correctional facility hospital
apartment other    
Cost of accommodation
Name of landlord Phone
FINANCIAL SITUATION (indicate gross income per month)
Employment OWA ODSP
Personal Savings OSAP Insurance Benefits
Living allowance Pension Other
(If your income is OWA or ODSP, provide the name/PH of your worker)
Name Phone
Days and times to reach your worker
LIVING WITH OTHERS
Have you lived in a group setting prior to this date? no yes
If yes, with whom?
Why do you want to live at Daybreak?
How do you feel about sharing a kitchen/living room/bathroom?
Briefly describe some of your house cleaning skills
Briefly describe some of your cooking skills
ACTIVITIES (please check activities in which you are involved)
volunteer work employment school/training
recreation therapy AA/AN meetings
support group life skills training other
Name each of the agencies, schools, employers, meetings, therapists, etc.
State the days & times of involvement in each activity
MEDICAL HISTORY
O.H.I.P. number
Family doctor Phone
Address of family doctor
Do you live with and emotional and/or mental health diagnosis?
no yes
If yes, please complete the following questions
What is your diagnosis?
Name of Psychiatrist/Psychologist
Address of clinic/hospital
Clinic/hospital phone
How often do you see your Psychiatrist/Psychologist?
Are you currently taking medication? no yes
If yes, what medication(s)?
How long have you been taking medication?
When do you take you medication?
Do you have a social worker for additional support? no yes
Name Agency Phone
Do you have a chemical addiction diagnosis? no yes
If yes, please answer the following questions
How long have you used drugs or alcohol?
Are you receiving addiction counseling? no yes
Name of agency or centre
Name of counselor Phone
Do you have allergies? no yes   To what?
Medic alert bracelet? no yes   Use an EPI pen? no yes
Do you use other prescription medication? no yes
Name of allergy medication
Is your allergy life threatening? no yes
REFERENCES
(you must provide 3 references with accurate phone numbers )
Landlord Phone
Psychiatrist/Psychologist Phone
Social Worker/Counselor Phone
Outreach Worker Phone
Family Doctor
(who knows you well)		 Phone
Employer Phone
Volunteer Supervisor Phone
Teacher Phone
REFERRED TO DAYBREAK BY
Referral Name Phone
Agency (if applicable)
(* = required fields)