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Apatisiwin Integrated Intake
Apatisiwin Integrated Intake
admin
2022-10-31T14:12:46+00:00
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Universal Consent
Release Of Liability
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Release Of Liability Policy Page
Personal Information Consent Policy
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Personal Information Consent Policy Page
Profile & Details
Name
(Required)
First
Last
Preferred Pronouns
(Required)
She/Her
He/Him
They/Them
Ze/Zir
Other
Preferred Pronouns
(Required)
Your Date Of Birth
(Required)
MM slash DD slash YYYY
Age
(Required)
Marital Status
(Required)
Please select an Option
Single
Common Law
Married
Divorced
Widowed
Separated
# of Dependents
(Required)
Gender Identity
(Required)
Male
Female
3rd Gender
Agender
Androgynous
Cisgender
Demigender
Gender Fluid
Gender Neutral
Gender Queer
Man/Boy
Neutrois
Non-Binary
Pangender
Transgender
Two-Spirit
Other
Please list your Gender Identity
(Required)
Indigenous Status
(Required)
First Nations - Registered
Firs Nations - Non-Registered
Métis - Registered
Métis - Non-Registered
Inuit - Registered
Inuit - Non-Registered
Non Status
SIN #
(Required)
Preferred Service Language
(Required)
Band/Home Community
(Required)
Indigenous Identity
(Required)
Please select an Option
Algonquin
Anishinaabe
Blackfoot
Cayuga/Guyohkonyo
Cherokee
Cree
Delaware
Dene
First Nations
First Nations - Unidentified
Haudensaunee
Innu
Inuit/Inuk
Lenape
Maliseet
Métis
Mi'kmaq
Mississauga
Mixed
Mohwak
Navajo
Non-Indigenous
Not Applicable
Odawa
Oji-Cree
Ojibwe
Client Contact Information
Do you have a permanent address?
(Required)
Yes
No
Location Type
(Required)
Please select an Option
Correctional Facility
Emergency Housing
Group Home
Home Owner
Renting
Hospital
Seniors Living
Shelter
Staying with Friends/Family
Subsidized Housing
Transitional Housing
Treatment Centre
Unhoused
Address
(Required)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
On/Off Reserve
(Required)
On Reserve
Off Reserve
Indigenous Housing
(Required)
Yes
No
Phone #
Voicemail Allowed?
Yes
No
Email Address
Are you currently employed?
(Required)
Yes
No
If yes, Where?
Do you have reliable transportation?
(Required)
Yes
No
Do you have a valid drivers license?
(Required)
Yes
No
Emergency Contacts
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone
Education
What is you current level of completed education?
(Required)
None
Early Childhood Education
Grade School
High School
College
University
Apprenticeship
Post Graduate
Other
(Other) Please Specify:
(Required)
Health & Mental Health
Do you have any disabilities?
(Required)
No
Yes
Prefer Not To Answer
Is you disability diagnosed?
(Required)
Suspected/Self-Identified
Diagnosed
Which Disability?
(Required)
Please select an Option
Anxiety
ADHD
Autism
Dementia/Cognitive Impairment
Fetal Alcohol Spectrum Disorder (FASD)
Hearing Impairment
Learning Disability
Obsessive Compulsive Disorder (OCD)
Oppositional Defiant Disorder (ODD)
Physical Impairment
Visual Impairment
Other
Prefer Not To Answer
(Other) Please Specify:
(Required)
Do you have a mental health diagnosis?
(Required)
No
Yes
Prefer Not To Answer
Which Diagnosis?
(Required)
Please select an Option
ADD
Dementia
Eating Disorder
Major Depressive Disorder
Narcissistic Personality Disorder(NPD)
Obsessive Compulsive Disorder (OCD)
Pain Disorder
Paranoid Personality Disorder
Post Traumatic Stress Disorder (PTSD)
Psychotic Disorder
Schizophrenia
Prefer Not To Answer
Other
(Other) Please Specify:
(Required)
Please Upload Your Resume
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Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 32 MB, Max. files: 3.
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