PSRC Intake Form - CARMIS Smart Forms - Aurora Family Therapy Centre

Refugee Claimants - Intake Form

Your Personal Details

First Name(Required)

Middle Name

Last Name

Preferred/Other Name

Date of Birth(Required)

Marital Status(Required)

Gender(Required)

Email Address(Required)

Phone Number(Required)

Secondary Phone

Previous Profession

Preferred Service in(Required)

Native Language(Required)

Other Spoken Languages (if applicable)

Number of Adults in your Household

Number of Children in your Household

Current Residential Address

Address(Required)

Apt/Unit #

City

Province(Required)

Postal Code(Required)

Immigration Related Information

Status in Canada(Required)

Point of Entry (Port, border point)(Required)

Date of Arrival in Manitoba

Country of Birth

Country of Origin

Country of Last Residence

Have you submitted your claim?

If not, are you in need of a referral?

Emergency Contact Information

Full Name(Required)

Phone Number(Required)

Email(Required)

Relationship(Required)

Consents and Confidentiality Statement

Mail Consent

I consent to be added to the mailing list for information on events and workshops.

I consent to your organization collecting, storing, and using my personal information for the purposes of providing services and communications related to events, workshops, and other relevant activities. I understand that appropriate security measures will be in place to protect my data from unauthorized access or misuse.

I consent to the sharing of my personal information with trusted third-party partners of your organization solely for the purpose of delivering services and communications as described. I am aware that I have the right to withdraw my consent at any time, which may impact the services provided to me.

Date

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Signature(Required)

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