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(587) 787-4486
Lethbridge, AB
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Services
About
Forms
Client Referral
Intake Form
Community
Calendar
Contact Us
Contact Us
New Client Intake Form
"
*
" indicates required fields
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CLIENT PERSONAL INFORMATION
Today's Date
*
MM slash DD slash YYYY
Full Name
*
First
Middle
Last
Home Address
*
Street
City
Postal Code
Primary Phone
*
Secondary Phone
*
Your Email Address
*
Age
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Two-Spirited
Indigenous
*
Yes
No
Band
Treaty Number
Marital Status
*
Single
Maried
Divorced
Widowed
Common-Law
Spouse Name (First & Last)
Would they also require support
Yes
No
Children in your care
*
Yes
No
Number of Children
Children Registered to your Band
Yes
No
If you answered No, Please explain
*
Names of children in your care:
Child Name (First & Last)
Child's relationship to you
Child Name (First & Last)
Child's relationship to you
Child Name (First & Last)
Child's relationship to you
Child Name (First & Last)
Child's relationship to you
Child Name (First & Last)
Child's relationship to you
Child Name (First & Last)
Child's relationship to you
Emergency Contact Name
*
Phone Number
*
Relationship
*
CLIENT'S CURRENT SUPPORT'S
Source of Income
Employed
Student Allowance
Alberta Works
AISH
Old Age Pension
Other
None
If you answered Other or None. Please explain
*
Total amount of monthly income (include all sources of income) $
*
Please list all agencies you’re currently working with
Please list all agencies you’ve worked with in the past year
Referred by (Name of Agency)
Referred by (Name of Worker)
CLIENT REQUESTED SUPPORT
Support being requested
*
Housing Support
Homeless Prevention Support
Employment Support
Addiction Support
Mental Health Support
Financial Support
Cultural Support
Legal Support
Other
Please explain in your own words what brought you to Blackfoot Resource Hub for support
*
CLIENT CONSENT TO DISCLOSE INFORMATION & SIGNATURE
I,(Type Name)
*
, consent to give Blackfoot Resource Hub permission to make calls on my behalf to different agencies that may be able to support me.
Client Signature
*
By inputting your name above, you are deemed to have electronically signed this application form.
Today's Date
*
MM slash DD slash YYYY
Staff Witness Signature
*
By inputting your name above, you are deemed to have electronically signed this application form.
