Intake Form

Service Area
Not sure which to pick? Read about our services on our website lifespin.org
Referral Type
Agency Referral are for caseworkers and service providers only.
The following fields are all hidden by default and show conditionally based on the service area.
Children & Youth Programs:
LIFE*SPIN is partnering with Ashley Homestore to provide our families with Beds this Christmas. Families who qualify will recieve a twin bed frame, mattress, pillow, coverlet, and sheet set. Ashley Homestore will ship the bed directly to the family in need and have it set up for them.

This program is for children ages 3 to 16 who are currently without a bed. The family needs to be surviving on low-income or transitioning out of a shelter. You can learn more about the program at: https://ashleyhomestore.ca/pages/hope-to-dream

If you qualify, LIFE*SPIN will send your family's information to Ashely Homestore. From there Ashley Homestore will be contacting families to set up delivery. Delivery will be expected in December.

Please fill out the form below with the nessary informaiton. We will contact you to let you know the status of your application.

Please note that this program is only available to current LIFE*SPIN clients.

If you are in need of multiple beds you will have to fill out a form for each child.
By selecting this box you are giving consent for us to share your information with Ashley Homestore, who will be administering the Hope to Dream program.
Nutrition Program
Are you registering for the Prom Shopping Day on Saturday, April 25, 2025, from 10 AM to 4 PM?
How many people will be coming with you to the Prom Shopping Day?
How did you learn about LIFE*SPIN's Program?
Name of the Child Receiving the Bed
Age of Child Receiving the Bed
Agency Referral
Thank you for reaching out, this form is for caseworkers and service providers making a referral on behalf of a client. After completing this form, we will contact you to confirm that the Community Advocate services are the right fit for the client being referred.

Please provide your full name, phone number, email, and agency name below.
Caseworker Full Name

First NameLast Name
Caseworker Phone Number
Please enter a valid phone number.Format: (000) 000-0000 .
Extension
Caseworker Email
example@example.com
Agency
IMPORTANT

The Community Advocate DOES NOT provide direct assistance with the following, (but may be able to provide resources and referrals):

- Finding Housing

- COHB - Canadian Ontario Housing Benefit (Please refer to Housing Access Center)

- Assistance with Rent or Utilities (Please refer to Housing Stability Bank)

- Finding a Lawyer

- Providing Legal Advice/Assisting with Legal Matters

- OW/ODSP Appeals/Internal Reviews (Please refer to Neighbourhood Legal Services)

- Landlord and Tenant Matters (including evictions)

- Obtaining Personal ID

- WSIB or EI Matters/Applications

- CRA Matters (tax issues, CRA account issues, Benefit Applications such as Canada Child Benefit, etc.)

If you need assistance with any of the above, please do not fill out an intake form and call the office; we will do our best to direct you to the appropriate service or resource.
Is the Community Advocate right for your client?

Below is a full list of services provided by the Community Advocate. If you do not see the service your client needs listed, please call our office so we can help direct you to the appropriate service or resource.
Advocacy: help is required to complete the application forms for:
Advocacy Short
Event/Workshop Info:
Tax Years
Please list the tax year(s) you would like help filing.
🌱Seed Planting Party
Come join us on April 24 from 1PM to 3PM for our Seed Planting Party. We’ll have fun activities, and you can get your hands dirty planting seedlings for our Pocket-Sized Farms Program.

This event is for Children of all ages! Each child will have the opportunity to start some of their own seedlings to bring home.

When: Friday, April 24, from 1PM to 3PM

Time: 1:00PM to 3:00PM

Location: LIFE*SPIN Office, 866 Dundas Street, London, ON

If you are driving you can park at the Western Fair Market. LTC Bus routes 2 and 20 also stop near the LIFE*SPIN Office.
In the box below please provide the name and ages of the children who will be attending Seed Planting Party:
🍅Pocket Sized Farms 2026
Child's First Name
Child's Last Name
Age of Child
Child Information
Please provide any additional information you would like us to know about you child, such as dietary restrictions and accommodations.
To help customize your kits, please tell us how will you be gardening this year?
When we deliver your gardening kit, would you be interested in a demonstration by our volunteers on double digging your garden plot?
Not sure what double digging is? Click Here to learn more about starting your garden and preparing your soil.
This year we have two community garden plots where we will be regularly meeting for activities. Please let us know which location(s) you will most likely visit:
The community garden plots need to be started in May, so they are prepared ready for kids to explore in the summer. Would you be interested in helping maintain the community garden at Ed Blake Park?
The community garden plots need to be started in May, so they are prepared ready for kids to explore in the summer. Would you be interested in helping maintain the community garden at Thames Park?
Client Contact Information
Please provide the participant's Parent/Guardian information in the section below. We will be delivering gardening kits, so please ensure that the contact information and address sections are correct.
Prefill
First Name
Last Name
Pronouns:
Please input the names of all the individuals in your family who will need to shop at the Free Store.
Date of Birth

DayMonthYear
Email is {email36}
Email

Confirmation Emailexample@example.com
Phone Number
Please enter a valid phone number. Do not include a preceding 1, even if your number is long distance.Format: (000) 000-0000.
Select if there is an alternate contact you would like to include:
Name and phone number (including extension) of alternate contact:
Address

Street Address

Unit Number

CityProvince

Postal Code
City
City
Province
Province
Postal Code
Postal Code
Buzzer Number
If you live in an apartment building, enter the buzzer number
Please double check this address information, including the unit number. If the address is incorrect you may not receive the service you have requested.
Household Information

The mission of LIFE*SPIN is to provide information and support for individuals who are surviving on low incomes
Household Information
Your partner's first & last name
Languages spoken in the home

Other
Do you need an interpreter?
IMPORTANT

Please note that we currently only have a volunteer interpreter for Arabic, Greek, and Spanish, therefore limited appointments are available and wait times will be longer. If you speak any other language you will have to provide your own intperpreter.

For Clients on OW or ODSP: Please reach out to your caseworker to make arrangements for a free interpreter through Accross Languages to attend your appointment. Doing so will allow us to see you faster.
IMPORTANT

Please note that we currently only have a volunteer interpreter for Arabic, Greek, and Spanish, therefore limited appointments are available, and wait times will be longer. If you speak any other language you will have to provide your own intperpreter.

To ensure your client can be seen in a timely manner please support them in securing an interpreter for their appointment. Otherwise it could take months before we can see them.

For Clients on OW or ODSP: please make arrangements for an interpreter through Accross Languages to attend their appointment.
Sources of household income (please check all that apply)

Other
Income Sources
How many adults (18+) live in your household?

Please enter the number of people who live in your household, by age category:

Rows	Male	Female	Non-Binary
Age 0-6
Age 7-12
Age 13-18
Age 19-25
Age 26-64
Age 65+

Is anyone in your household pregnant?
If yes, date the baby is due.

MonthDayYear
Children Ages 0-12
Tables Field
Youth Ages 13 - 25
Tables Field
Adults Ages 26 - 64
Seniors 65+
Tables Field
Children 7-12
Tables Field
Girls Ages 13-18
Tables Field
Children 18 and under
Tables Field
How many of these adults are 60+?
How many children live with you (less than 18 years old)?
Child Information
Today

MonthDayYear
Would you like to receive our newsletter and be notified of new programs that might interest you?
You can view our Privacy Policy at: https://www.lifespin.org/what-we-do
Should be Empty:

The following fields are all hidden by default and show conditionally based on the service area.

Agency Referral

Is the Community Advocate right for your client?

🌱Seed Planting Party

🍅Pocket Sized Farms 2026

Client Contact Information

Please provide the participant's Parent/Guardian information in the section below. We will be delivering gardening kits, so please ensure that the contact information and address sections are correct.

Household Information