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Client Application

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  • Which one of our offices are you applying to? * Required
  • Name * Required
  • Date Format: DD slash MM slash YYYY
  • Address * Required
  • Date Format: YYYY slash MM slash DD
  • Are you a Canadian citizen? * Required
  • If no, what is your country of origin and year of arrival in Canada?
  • Do you currently have a Doctor or Nurse Practitioner? * Required
  • Do you have a family member from the same household that is already a client at the CKCHC? * Required
  • NameBirth Date (dd/mm/yyyy)Health Card Number (please include version code and expiry date)SexRelationship 
  • Do you have communication problems that make accessing health services difficult? * Required
  • Do you require a translator? * Required
  • What is your mother tongue (first language learned)? * Required
  • If your mother tongue is not English or French, are you most comfortable with English or French?
  • What language are you most comfortable using? * Required
  • What is your annual income? * Required
  • Does 2/3 or 66% of your income go towards food and housing? * Required
  • Are you or is there a possibility you could be pregnant?
  • Are you temporarily in the community as a seasonal worker?
  • Race/Ethnic Origin: * Required
  • Gender: * Required
  • Sexual Orientation: * Required
  • Current Household Composition: * Required
  • Highest Education Level Completed:
  • Are you currently or have you seen a Therapist or Counsellor? * Required
  • Are you currently or have you seen a Psychiatrist? * Required
  • Are you currently or have you seen any Specialists? * Required
  • NameDoseDirections 
  • Do you have any of the following? Please check ALL that apply: * Required
  • Your personal and medical information as documented above will be sent to the CKCHC reception team via electronic mail. * Required
  • RAPID REFERRAL

    This section is to be completed by a person from an approved rapid referral organization only. *Please fill out section completely*
  • Name:Phone Number:Ext.:
  • Organization:
  • Is your Client aware that this referral has been made?
  • Is your Client stable?
  • **Client must have a diagnosed SMI and be without a Doctor or Nurse Practitioner to qualify. Please ensure a diagnosis has been checked above**

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