CANADIAN MENTAL HEALTH ASSOCIATION



C.M.H.A. H.K.P.R. Employment Supports Referral FormReferral / Request for Service Application FormThe mission of CMHA- HKPR is to work with individuals, families and community partners in providing services to promote and enhance the mental health and wellness of those living within the communities we serve. A. PERSONAL INFORMATION:Last name: FORMTEXT ????? Date: FORMTEXT ?????First name: FORMTEXT ?????Social Insurance Number : FORMTEXT ?????Address: FORMTEXT DOB: FORMTEXT ?????Gender: FORMTEXT ????? City: FORMTEXT ?????Postal Code: FORMTEXT ?????County: FORMTEXT ????? Country of Citizenship: FORMTEXT ?????Telephone: FORMTEXT ????? Can we leave a message FORMCHECKBOX Yes FORMCHECKBOX No Alternate #: FORMTEXT ?????Email: FORMTEXT ?????Language Spoken: FORMTEXT ????? Do you Identify as Aboriginal: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownCulture :Current Employment Status (Check all that Apply): FORMCHECKBOX Employed 20 + hrs/ week FORMCHECKBOX Employed under 20 hrs /week FORMCHECKBOX Job Change/ Crisis FORMCHECKBOX Unemployed FORMCHECKBOX Interested in Employment Skills/ Education FORMCHECKBOX Volunteer Work FORMCHECKBOX Self Employed FORMCHECKBOX Job AdvancementCurrent Legal Status (Check One): FORMCHECKBOX No Legal Problems/Pardon Granted FORMCHECKBOX Incarcerated FORMCHECKBOX On Probation FORMCHECKBOX Awaiting Trial FORMCHECKBOX On Parole FORMCHECKBOX NCR/ORB FORMCHECKBOX Court Diversion FORMCHECKBOX Criminal Record FORMCHECKBOX UnknownCurrent Residential Status (Check One): FORMCHECKBOX Hospital / Facility FORMCHECKBOX Homeless FORMCHECKBOX Non-Profit / Subsidized Housing FORMCHECKBOX Market Rent Apartment FORMCHECKBOX With Parents / Primary Caregiver FORMCHECKBOX Rooming / Boarding House B. REFERRAL SOURCE: (Check One) FORMCHECKBOX Self FORMCHECKBOX CMHA-HKPR (Peterborough - Internal Transfer) Staff Completing: FORMTEXT ????? FORMCHECKBOX Other Name: FORMTEXT ????? Agency (If Applicable): FORMTEXT ????? Relationship to Client:: FORMTEXT ????? Telephone: FORMTEXT ????? Email: FORMTEXT ????? Consent Attached?: FORMCHECKBOX Yes C. EMERGENCY CONTACT: NAME: FORMTEXT ?????TELEPHONE: FORMTEXT ?????Substitute Decision Maker? FORMCHECKBOX Yes FORMCHECKBOX No A Substitute Decision Maker is a person authorized under PHIPA to consent, on behalf of an individual, to disclose personal health information about the individual.Relationship to Client: FORMTEXT ?????Revised 2019E. WHAT OTHER SERVICES ARE YOU CURRENTLY INVOLVED? (Check all that apply and name) FORMCHECKBOX COMMUNITY HEALTH SERVICE: (eg. ACT Team) FORMTEXT ????? FORMCHECKBOX Consent attached FORMCHECKBOX HOSPITAL OUTPATIENT PROGRAM / SERVICE: FORMTEXT ????? FORMCHECKBOX Consent attached FORMCHECKBOX EMPLOYMENT SERVICE: FORMTEXT ????? FORMCHECKBOX Consent attached FORMCHECKBOX COMMUNITY Supports – General (List all): FORMTEXT ????? FORMCHECKBOX Consent attachedF. INCOME SOURCE: What is your Primary Source of Income? FORMCHECKBOX Eligible for or Receiving Employment Insurance FORMCHECKBOX E.I. Parental Benefits FORMCHECKBOX Workplace Safety FORMCHECKBOX CPP FORMCHECKBOX Accident/Sickness/Disability Insurance FORMCHECKBOX Ontario Works FORMCHECKBOX ODSP Income Support FORMCHECKBOX Other: FORMTEXT ?????G. Education What is the highest level of Education you have attained? FORMCHECKBOX Some Elementary FORMCHECKBOX Completed Elementary FORMCHECKBOX Some High School FORMCHECKBOX High School ( OSSD) FORMCHECKBOX Some College FORMCHECKBOX Completed College FORMCHECKBOX Some University FORMCHECKBOX Completed University FORMCHECKBOX Some Apprenticeship FORMCHECKBOX Completed Apprenticeship/ Red Seal FORMCHECKBOX Other: FORMTEXT ?????H. Do you identify with any other barriers to Employment: FORMCHECKBOX Physical / Mobility FORMCHECKBOX Mental Health/ Psychiatric FORMCHECKBOX Deaf / Hearing Impairment FORMCHECKBOX Chronic Illness FORMCHECKBOX Developmental Disability FORMCHECKBOX Blind / Visually Impaired FORMCHECKBOX Learning Disability FORMCHECKBOX Substance Use FORMCHECKBOX Agility FORMCHECKBOX Head Injury/ Cognitive FORMCHECKBOX Childcare Needs FORMCHECKBOX Transportation DIAGNOSIS / HEALTH INFORMATION: Psychiatric Diagnosis: FORMTEXT ????? Do you identify with a mental health concern? FORMCHECKBOX Yes FORMCHECKBOX No Diagnosed by (Psychiatrist): FORMTEXT ????? FORMCHECKBOX Anxiety FORMCHECKBOX Depression FORMCHECKBOX Bipolar Disorder FORMCHECKBOX SchizophreniaDate: FORMCHECKBOX Borderline Personality Disorder FORMCHECKBOX PTSD FORMCHECKBOX Other – please specify: _______________________________ Physical Disability/ Diagnosis: Diagnosed by (Doctor): Date: Other medical conditions/disabilities check any that apply: FORMCHECKBOX Concurrent Disorder (Substance Abuse) FORMCHECKBOX Dual Diagnosis (Intellectual Disability / Developmental Disability) FORMCHECKBOX Acquired Brain Injury FORMCHECKBOX Other Physical Disability please specify: FORMTEXT ?????Additional Comments: FORMTEXT ?????-82552063750036766501574800Applicant SignatureDate-5816601517650Staff SignatureDate85725105410047625596900Revised 2019 ................
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