CLIENT APPLICATION
*Answering as many questions as possible will help us to better meet your needs and provide continuity of care in a safe environment*
PROTECTED AND CONFIDENTIAL WHEN COMPLETED: Thank you for completing this form. The Chatham-Kent Community Health Centres’ staff operates
as a team to provide the best possible service for our clients. You may deal with more than one staff member which means that staff may need to share
personal information to help you. All information is kept confidential. Some of the information that you will provide in the Client Intake Form is required
by the Ministry of Health and Long-Term Care. This information will enable us and our funders to determine plans for and deliver programs specific to the
need of the Community Health Centres’ clients. With your consent, we release this information; however, no names or personal identifiers will be used.
I have read and/or understand the above information and give consent to the items herein:
Signature
Date
PART 1: GENERAL IDENTIFYING INFORMATION
Last Name: __________________________________________ First Name: __________________________________________________
Gender:
Female
Male
Intersex
Trans – Female to Male
Other (please specify):___________________________________
Trans – Male to Female
Do not know
Two-Spirit
Prefer not to answer
O
t (Apt. #)
(No. and Street)
(City, Postal Code)
h
No Fixed
Shelter (please specify): _________________________________
e Address:
r #: ____________________________ Cell #: __________________________ Work #: ________________________________
Home Phone
Address:_________________________________________________________________________________________________________
Date of Birth: M______________/D_______/Y__________________ Age: _____ ____
Health Card #: __________________________ Version Code: _____Expiry Date: __________ OR Interim Federal Funding #:___________
No Insurance
Other form of Health Coverage (please specify): ___________________________________________
Emergency Contact Name: _______________________________________________
Phone #: ________________________________
Address: ________________________________________________________Relationship to you: ________________________________
Current Health Care Status:
Do you currently have a family physician / nurse practitioner:
No
Yes
If yes, current doctor’s/nurse practitioner’s name & Phone #: _____________________________
If yes, reason for leaving current practice: _____________________________________________
If no, where do you currently receive your health care? __________________________________
If no, name of previous family physician/nurse practitioner: ______________________________
All children under the age of 16, living at your address, who will be attending the Chatham-Kent Community Health Centres (please fill
out a separate form for each family member over the age of 16):
Name
Health Card Number
Expiry
Sex
DOB (M/D/Y)
Relationship
Date
PART 2: SOCIO-DEMOGRAPHIC INFORMATION
Languages:
Spoken in the Home: ____________________________________
Written Language(s): _______________________________
Official:____________________________________
Do you have communication problems that make accessing health services difficult? Yes
Translator required? Yes
No
No
Racial or Ethnic Group:
Asian – East
Asian – South
Black – North American
First Nations
Latin American
Metis
White – North American
Do not know
Mixed heritage (please specify): ___________________
Asian – South East
Black – African
Black – Caribbean
Indian – Caribbean
Inuit
Indigenous/Aboriginal
Middle Eastern
White-European
Prefer not to answer
Other(s) (please specify): _______________________
Sexual Orientation:
Bisexual
Two-Spirit
Gay
Do not know
Country of Birth:
Canada
Other (please specify): _______________________
Canadian Citizen:
Yes
No
Heterosexual (straight)
Prefer not to answer
Are you a temporarily in the community as seasonal worker?
Marital Status:
Single
Divorced
Number of Children: _________
Place of Residence:
Married
Common-Law
Lesbian
Queer
Other (please specify): ___________________________
Yes
No
Separated
Widowed
Are you or is there a chance that you could be pregnant?
Private Home
Parent Home
Apartment
Child Home
Yes
Shelter
Homeless
Other: __________________
Current Household Composition:
Sole Member
Couple
Single Parent Family (Mother)
Single Parent Family (Father)
Siblings
Unrelated Housemate
Other ____________________________
Couple with Children
Parent living with Adult Child
Grandparents with Grandchildren
Number of people living in household that bring in an income: ___________
Number of people living in household supported by this income: _________
Does 2/3 of your income go towards housing and food?
Yes
No
Please List All Medications
Name of Medication
Dosage
Instructions
Name of Pharmacy: ___________________________________
Have you had a hospital stay within the last three months?
Yes
No
Are you or have you seen a therapist/counselor?
Yes
No
Do you currently or have you in the past seen a psychiatrist?
Yes
No
If Yes, please list name and year last seen: ____________________________________________
No
Do you have any of the following (please check all that apply to you)?
Chronic illness (ex. diabetes, COPD, CHF)
Developmental disability (ex. ADHD, autism)
Addictions (ex. drug or alcohol)
Learning disability (ex. dyslexia)
Mental disorder (ex. bipolar disorder, schizophrenia)
Physical disability (ex. arthritis, cerebral palsy)
Sensory disability (ex. vision impairment, hearing impairment)
Other (please specify): _______________________________
None
Do not know
Prefer not to answer
Do you receive care from:
Canadian Mental Health Association (CMHA)
Assertive Community Team (ACT TEAM)
How did you hear about us:
Health Care Connect
Newspaper
Yes
Yes
Radio
Word of mouth
No
No
Emergency Room
CKCIS
Other_______________________
CKCHC Staff Use Only
Reviewed & Approved by: ______________________________________
Name
Date
Reviewed & Approved by: ______________________________________
Name
Date
Target Populations Met:
Economically disadvantaged
Youth (13-21)
Communication Barriers
Emotional or Mental Health
First Nations
Family Member
Addictions
Seasonal Worker
Pregnant
Declined: _________________________________________________
Reason: _________________________________________________
PART 3: CONSENT TO OBTAIN PERSONAL INFORMATION
To provide the best possible service for our clients it is most helpful to have your past medical records from
your previous doctor or nurse practitioner and/or specialist you have or currently see. With your consent, we
will contact those previous providers to send us your records to have on file and assistant in your future health
care at the Chatham Kent Community Health Centres.
NAME: _________________________
DOB (M/D/Y): __________________________
HC#: ___________________________
I hearby authorize the following office or person(s) to release the following personal information about me:
1. Designated Office/Person(s): _________________________________________________________
Information to be released: __________________________________________________________
2. Designated Office/Person(s): __________________________________________________________
Information to be released: __________________________________________________________
3. Designated Office/Person(s): __________________________________________________________
Information to be released: ___________________________________________________________
This information may be release to the following individual: ______________________________________
Signature: ______________________________
Date: ______________________________
Witness: _______________________________
Date: ______________________________