CENTER FOR INNER RELIEF- intake form +

CFIR

APPLICATIONN FORM

Please provide the following details so we can better understand your needs and tailor services to support your journey.

1 Full Name

2. Date of Birth (DD/MM/YYYY):

Address

Street Address Line 2

City

Postal Code

4. Phone Number

5 Email Address

example@example.com

6. Preferred Contact Method: Phone Email

Emergency Contact Information 7. Full Name:

7 Full Name

8. Relationship to Client: 9. Phone Number:

8 Relationship to Client

Service Area(s) of Interest Please check the services you are seeking assistance with:
Life & Career Coaching Family
Family & School Mediation Services
Concierge Services -for Seniors
Senior-Caregiver Consultation
Systems Navigation Services
Immigrant Coaching Services
Addictions Coaching
Case Management for Housing Support
Personal Goal Setting & Development
Medical Proxy and Guardianship Services
Return-to-Work Disability Management
Family & School Mediation Services

Social Services System Navigation
Relationship Coaching Technology Addiction Support Parenting Support
Self-Sabotage Amendment
Other, please specify

Other please specify

Please answer the following questions to help us understand your background and tailor our services to your needs.

1. Have you previously accessed similar services?

If yes, please describe:

2. Current Employment Status:

Are you curently Employed, Unemployed Self-employed, Student Other (please specify): _________________________________

3. Medical Proxy and Guardianship

Are you seeking consultation to enhance your understanding of the complexities associated with becoming or assigning a caregiver, guardian, power of attorney? Responsible to give medical consent and assignee choice and other relevant factors with decision making? _________________

If yes, please provide details: Who is seeking services?

4. Are you currently receiving any mental health or medical treatment?

If yes please provide the name of your doctortherapist and their contact information

Please indicate specific goals or challenges you are hoping to address through our services.

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5 What are the main career or personal goals youd like to focus on

6. Are you experiencing any specific challenges in your career or personal life?

____________________________________________________________________

___________________________________________________________________

7 What family or school related issues would you like to address

Housing Support & Case Management Services 8. Are you currently facing any housing-related challenges (e.g., maintenance, relocation, eviction)? Yes

Concierge Services for Seniors

9. Are you or someone you care for in need of assistance with transportation, errands, or service coordination?

If yes please list the areas where help is needed

Caregiver Consultation

10. Are you currently providing care to someone with a disability, illness, or aging condition?

If yes what specific support or advice are you seeking

Return-to-Work Disability Management 11. Are you currently dealing with a disability that affects your ability to work?

If yes please provide details of the disability and your current situation

Parenting & Relationship Coaching

12 What specific challenges are you facing in your role as a parent or in your relationships

Technology Addiction & Self-Sabotaging Behaviors 13. Do you experience challenges related to technology use (e.g., screen time, social media addiction)?

If yes please describe

14. Have you ever experienced self-sabotaging behaviors (e.g., procrastination, negative thinking patterns)?

If yes please describe

15. Are you a newcomer to Canada?

No

If yes what specific challenges are you experiencing as an immigrant

We are committed to protecting your privacy and ensuring that your information is kept confidential in compliance with Canadian privacy laws (PIPEDA) and New Brunswick's Health Information Protection Act (HIPA

1. Consent to Use of Information

By signing below, you consent to the collection, use, and sharing of your information for the purpose of providing services. Your personal information will be handled in accordance with the privacy policies of this agency. I consent to the use of my personal information for service purposes.

2. Consent to Participate in Services

I agree to participate in the services offered by the agency. I understand that I may withdraw from services at any time.

16. How did you hear about our services?

Referral (please specify): Website

Referral please specify

Community Event Other (please specify):

Community Event

Other please specify

Signature & Date By signing below, you acknowledge that all information provided is accurate and true to the best of your knowledge. Client's Signature: Date:

Date

Clients Signature

Agency Representative Signature: Date:

Date

Agency Representative Signature

Thank you for your application. Your responses will help us provide tailored services to support your journey. If you have any questions or concerns, please feel free to reach out to our team.