Health & Wellness Intake Form
Summit Housing and Outreach’s Health & Wellness Program offers safe, welcoming spaces where individuals can connect, share experiences, and build meaningful relationships. These social groups are designed to help clients overcome feelings of isolation and foster a sense of belonging, encouraging emotional healing and personal growth in various activities. By engaging with others in a supportive environment, clients are empowered to strengthen their social skills and restore their sense of community, ultimately improving their mental well-being and overall quality of life. Additionally, the program is completely free, ensuring that everyone has the opportunity to participate and benefit.
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PLEASE READ CAREFULlY: Consent to Collect, Use, and Disclose Information: By completing this intake form, I acknowledge that I understand the private and confidential nature of the information I am providing. I agree that this information will be used, collected, and disclosed only within Summit for the purpose of intake, meeting summaries, and notes related to my involvement. I understand that I can withdraw my consent at any time by providing proper notice to Summit, and that doing so will not affect any prior actions taken based on my consent. Group Guidelines: All group members are to be respectful towards one another. Facilitators & group members will work together to create a safe, supportive, and nonjudgmental environment. Confidentiality is essential ‐ what is discussed in the group stays in the group. If leaving the group while it is in session for any reason, please give a facilitator a thumbs up so they know you are okay. Otherwise support staff will follow you to ensure your well‐being and provide support if needed. Ask permission from other group members or facilitators before hugging or touching them. If you need additional support before, during, or after a group session, please reach out to your caseworker or ask the group facilitator to contact a Summit case worker to provide this support. Summit facilitators may be volunteer or peer workers and not be able to provide this level of support. Direct any issues/concerns/complaints with Summit Housing to your case worker or ask for contact information for a member of the management staff. Please, one person to speak at a time… no over‐talking. Do not give advice to other group members unless they ask for it; when asked for advice there is no obligation to respond unless you are comfortable doing so. Please do not use profanity when speaking, but profanity in your writing or artwork is fine. Be mindful of not dominating the conversation – it is important everyone has an opportunity to share. No ruminating about the same topic/issue continuously – staff may offer redirection if necessary. Watch your volume of speech, indoor voices please. Use designated smoking areas and cigarette disposal stations. Snacks and coffee/tea may be provided at a group session, a member bringing/buying food for the group is also acceptable. Materials borrowed must be returned at the end of each group session. By signing below, you are acknowledging you have read the above Summit Housing & Outreach Programs Group Guidelines and agree to abide by them. Failure to not respect and follow all group guidelines outlined above may result in your removal from the group. This may be a temporary or permanent removal determined by Summit Housing Management.
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Yes
No
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Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Aboriginal / Indigenous Origins?
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Yes
No
Prefer not to answer
Ethnicity
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Mental Health Diagnosis (If Any)
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Do you have any accessibility needs?
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Yes
No
If yes, please specify:
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Emergency Contact
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First Name
Last Name
Relationship
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Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Permission to disclose
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Yes
No
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Are you a current client of Summit?
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Yes
No
Referral Source
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CMHA
Halton Healthcare
Woodview
Summit
Support House
Thrive
Other
If Other, please specify:
Do You Have Any Other Supports in the Community? If Yes, What are they?
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Which groups are you interested in?
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Paint Group
Men's Group (Online)
Productivity Group (Online)
Yoga
Conservation Walk
Arts & Crafts
Beginners Drawing Group (Online)
Open Mic
Lunch & Learns
Mindfulness Group (Online)
Tech For All Ages
Early Risers (Online)
Poetry Group (Online)
Family Support Group
Cooking Group
Movie Mates
Music Makers
Not Sure Yet
Would you like to be added to Summit's newsletter and mailing list to receive updates on our programs and events?
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Yes
No
As most of our programs are located in Milton, we would like to know if you have transportation or if you will need assistance with commuting.
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I have my own transportation to Milton.
I will need assistance with commuting to Milton.
I am only interested in the online programs.
How did you hear about us? Select all that apply.
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Social / Community Services
Social media
Website or blog
Google/search engine
Referral
Self
Other
If other, please specify:
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I hereby confirm that all the information I have provided in this form is accurate and complete to the best of my knowledge. I understand that this information will be used to support my intake and service planning process. I consent to the collection, use, and storage of this information by Summit in accordance with privacy and confidentiality policies. I acknowledge that providing false or incomplete information may affect my eligibility for services. By signing My name below or submitting this form, I agree to the above statement.
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