Referral Form

LakeCity Works is a non-profit agency that offers free employment services to people living with mental illness. We provide support for those seeking assistance with resumes, interviews, networking, skills development, work experiences, career decision making and maintaining employment. Our service is mobile which means that we can meet you in the community if necessary. Service is available throughout the Halifax Regional Municipality (from Ecum Secum to Hubbards).

Please complete all areas of this form. Incomplete forms may cause delays.

If you are having any trouble filling out this form please call 902-465-5000 during our business hours Monday-Friday 8:30 AM to 4:30 PM.

Fax: 902-465-5009

Email: referral@lakecityworks.ca

First Name

Last Name

Country

Address Line 1

Address Line 2

City

Province

Postal Code

Birthdate mm/dd/yyyy

Gender Gender Male Female Other

Education (highest level completed)

Phone Number

Email Address

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 Email Address (if applicable)

Referring Agent Phone Number (if applicable)

Income Source

If other income is selected 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 strategies Paid employment Support in keeping a job Navigation Work readiness Education exploration Resume writing Volunteering Other

If other is selected 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 some symptoms you may be experiencing

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

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: Current Status Legal History: Current Status No criminal record Charges pending On parole On probation Current conditions

Please explain the nature of any offences and/or conditions

Record of charges and convictions in past

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)

To help you be successful at LakeCity it is important that you are connected to a community support person/agency. Please check all that currently apply to you. To help you be successful at LakeCity it is important that you are connected to a community support person/agency. Please check all that currently apply to you. Psychiatrist Family doctor Other community support Other employment agency None

Have you been fully vaccinated (2 doses) against COVID-19? Have you been fully vaccinated (2 doses) against COVID-19? Yes No

Referral Form

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