First Name

Last Name

Country

Address Line 1

Address Line 2

City

Province

Postal Code

Phone Number

Email Address

Birthdate mm/dd/yyyy

Gender Gender Male Female Other

Education (highest level completed)

Have you obtained paid employment within the last 5 years? Have you obtained paid employment within the last 5 years? Yes No

Have you ever been a client of LakeCity in the past? Have you ever been a client of LakeCity in the past? Yes No

Referring Agency (if applicable)

Referring Agent Name (if applicable)

Referring Agent Phone Number (if applicable)

Referring Agent Email Address (if applicable)

Income Source Income SourceEmployment Support and Income AssistanceDSP (Disability Support Program)EmploymentEmployment InsuranceCanada Pension Plan-DisabilityChild Tax BenefitsOther

If other, please explain

Income Assistance Caseworker Name (if applicable)

Income Assistance Caseworker Phone Number (if applicable)

Are you connected to the Employment Support Services (ESS)? Are you connected to the Employment Support Services (ESS)? Yes No

ESS Caseworker Name (if applicable)

ESS Caseworker Phone Number (if applicable)

What service(s) would help you in finding/keeping employment (Check all that apply) What service(s) would help you in finding/keeping employment (Check all that apply) Job search Paid employment Support in keeping a job Networking Education exploration Resume writing Interview prep Volunteering in community Recreation programs Volunteering at LakeCity Onsite supported employment Other

If other, please list

Do you identify yourself as currently having a mental illness? Do you identify yourself as currently having a mental illness? Yes No

If yes, please describe

Are you connected with mental health services? Are you connected with mental health services? Yes No

Please list some symptoms you may be currently experiencing

Has your mental illness affected your ability to work? Has your mental illness affected your ability to work? Yes No

If yes, please explain

Legal History Legal History No criminal record I have a criminal record

Please explain in detail the nature of the offences and charges/convictions. If no criminal record, type "NA"

Do you have any additional barriers? Do you have any additional barriers? Yes No

If yes, please check all that apply If yes, please check all that apply Physical disability Visual disability Intellectual disability Hearing impairment Speech impairment Other

Please describe how these additional barriers affect your ability to work (if applicable)

Please indicate if you are receiving support from the following: Please indicate if you are receiving support from the following: Psychiatrist Family doctor Community support Other employment agency None