Application Form General InformationAddressPhoneEmailDate of BirthSk. Hospitalization NumberGender Male Female TransgenderMarital Status Single Married Widow(er) Divorced Common-law OtherAboriginal Status First Nations Inuit Metis Non-status Non-indigenousCitizenship Canadian Permanent Resident/Immigrant Refugee Student VisaPlace of BirthVeteran No YesVeteran Canadian Armed Forces Former RCMPPreviousNextFinancial SituationSource(s) of Income (i.e. Pension, Employment, Social Services, etc.)?Approximate Monthly Income?PreviousNextEducation and Work ExperienceHighest level of schooling completed?At what age?Where?Specialized Vocational Training?PreviousNextWork ExperienceHave you worked within the last year?Where?What jobs have you held in the past?PreviousNextSocial SituationWho does your support system consist of? (i.e. friends, family, relatives, groups, etc.).What are your hobbies or areas of interest and how do you spend your time (day and evening)?PreviousNextOtherHow frequently do you use alcohol? Never Seldom Occasionally Weekly DailyHow frequently do you use drugs, other than those prescribed to you? Never Seldom Occasionally Weekly DailyDo you have outstanding criminal charges?Do you have difficulty managing your anger?PreviousNextPrevious Living SituationsPlease list your current living situation, and living situations over the past five years (i.e. apartment, Approved Home, Group home, etc.)Have you ever been evicted? If so, please explainPlease check off the skill areas you would like to improve Money Management Grocery Shopping Cooking/Nutrition Medication Management Illness Awareness Personal Hygiene Housekeeping Skills Social Skills Assertiveness Daily Structure/Routine Vocational Skills Community Involvement Problem SolvingWhat do you expect to gain from living here?PreviousNextPlans for the FutureTraining/EducationEmploymentSocial LifePreviousNextCommunity ContactFamily Doctor (Name & Phone)Family Doctor (For how long and how often?)Psychiatrist (Name & Phone)Psychiatrist (For how long and how often?)CMHN (Nurse) - Name & PhoneCMHN (Nurse) - For how long and how often?Crisis Management Worker (Name & Phone?)Crisis Management Worker (For how long and how often?)Financial Worker (Name & Phone)Financial Worker (For how long and how often?) Case Manager/Service Coordinator (Name & Phone)Case Manager/Service Coordinator (For how long and how often?) Other (Name & Phone)Other (For how long and how often?)PreviousNextMedicalWhat is your diagnosis?Please provide a brief description of how your illness affects you, including side effects, symptoms, etcWhat medication(s) are you taking and what are the dosages?How long have you been taking these medications?Do you administer your own medication? Yes NoFor how long?When was your most recent Physical Examination Dental Checkup Optical ExaminationPlease list any other physical/medical problems (including allergies)?Do you have any contagious or infectious diseases: (ex: HIV, AIDS, MRSA, Hepatitis, etc) How many times have you been hospitalized?In the last year Yes NoFor what reasonIn the last five years Yes NoFor what reasonPreviousNextIn Case of EmergencyRelationshipAddressTelephoneHomeWorkCellDo you have any questions or concerns?PreviousNextFor the Supportive Apartment Program, please provide two (2) landlord references.1Phone NumberYour Previous AddressWhen did you live there and for how long?2Phone NumberYour Previous AddressWhen did you live there and for how long?I understand that this application will not be processed unless all questions are fully answered. I understand that this application will not be processed unless all questions are fully answered. Previous Submit
