JFC Community Wellbeing Program Client Registration Form

JFC Community Wellbeing Program Client Registration Form
The Community Wellbeing Program supports residents of Jane and Finch and neighbouring areas by promoting mental health and overall wellbeing. The program, which serves anybody ages 13+, offers services delivered on a one-to-one or group basis.

For questions about the services we offer, please contact Community Wellbeing Program via email at cwbteam@janefinchcentre.org or via phone 416-663-2733 ext 217.

Please fill out the form below, and a staff member will contact you.
Applicant Information
Client name*

First NameLast Name
Date*

MonthDayYear
Date
Pronouns
Birthday*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Email
example@example.com
Interpreter needed?*

YesNo
If yes, what language?
Program Information
Which Community Wellbeing Programs are you interested in joining?*

Service Navigation (Ages 13-29)Service Navigation (Ages 30-55)Service Navigation (Ages 55+)GIT Program (Ages 30-55)GIT Connected (Ages 13-29)Seniors Program (Ages 55+)Spanish Speaking Seniors Program (Ages 55+)Other
Reasons for joining Community Wellbeing Programs:
Emergency Contact Information

In the event of an emergency, please provide a contact below:
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
How did you hear about the program?

Please check all boxes that apply
Please check all boxes that apply*

Other Jane/Finch Centre StaffCommunity Wellbeing Team StaffWord of MouthCommunity CentreSchoolHospital/Clinic/DoctorPoster or flyerCommunity EventSocial MediaBlack Creek Community Health CentreOther
Other (please specify)
If you are a service provider referring a client, please fill out the section below
Name

First NameLast Name
Agency or Clinic
Phone Number
Please enter a valid phone number.
Email
example@example.com
Signature of client or person completing form
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

JFC Community Wellbeing Program Client Registration Form

Applicant Information

Program Information

Emergency Contact Information

How did you hear about the program?

If you are a service provider referring a client, please fill out the section below

Signature of client or person completing form