Harmony House is a second-stage shelter for women and children who are survivors of violence. With this application, you can be considered for housing with Harmony House. The purpose of the form is to help us learn more about you and assess what your particular needs are. Please answer them completely and accurately. The confidentiality of the information you provide will be respected, though it may be used anonymously for statistical purposes. The completed form will be saved to our database and will not be transmitted by e-mail.

Personal Information

Current housing situation

Income Information

Please specify the monthly amount you receive from the following sources:

Information regarding the abuse

Types of the abuse experienced

Have you experienced any of the following?

Needs Assessment

Your declaration

This is your agreement with us. We promise that your confidentiality will be respected. You agree to what is set out below.

By submitting this application, you agree that you have done your best to ensure that the information provided in this application is correct.

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