Client Application

Which one of our offices are you applying to? * Required
- Walpole Island
- Chatham
- Wallaceburg
Name * Required
Given (First) Middle Last
Alias (if you do not go by given name)
Birth Date (dd/mm/yyyy) - must be dd/mm/yyyy format * Required
Date Format: DD slash MM slash YYYY
Address * Required
Street Number and Name Apartment City Province Postal Code
Home Phone Number
Cell Phone Number
Health Card Number
Version Code
Expiry Date - must be yyyy/mm/dd format
Date Format: YYYY slash MM slash DD
- Do Not Have a Health Card
Are you a Canadian citizen? * Required
- Yes
- No
If no, what is your country of origin and year of arrival in Canada?
Country Arrival
Do you currently have a Doctor or Nurse Practitioner? * Required
- Yes
- No
What is your current/previous Doctor's or Nurse Practitioner's name?
Do you have a family member from the same household that is already a client at the CKCHC? * Required
- Yes
- No
If Yes, what is their name?
List all children under the age of 16, living at your address and will be attending the Chatham-Kent Community Health Centres. Please fill out a separate application for family members over 16 years old.
Name Birth Date (dd/mm/yyyy) Health Card Number (please include version code and expiry date) Sex Relationship
Do you have communication problems that make accessing health services difficult? * Required
- Yes
- No
Do you require a translator? * Required
- Yes
- No
What is your mother tongue (first language learned)? * Required
- English
- French
- Other
If Other, please specify:
If your mother tongue is not English or French, are you most comfortable with English or French?
- English
- French
What language are you most comfortable using? * Required
- English
- French
- American Sign Language
- Arabic
- Low German
- Spanish
- Other
If Other, please specify:
What is your annual income? * Required
- $0-$19,999
- $20,000-$29,999
- $30,000-$39,999
- $40,000-$59,999
- greater than $60,000
- Do Not Know
- Prefer Not to Answer
Does 2/3 or 66% of your income go towards food and housing? * Required
- Yes
- No
How many people does this income support? * Required
Are you or is there a possibility you could be pregnant?
- Yes
- No
Are you temporarily in the community as a seasonal worker?
- Yes
- No
Race/Ethnic Origin: * Required
- Indigenous
- Inuit
- Metis
- Asian
- Black
- Latin American
- Middle Eastern
- White
- Other
If Other, please specify:
Gender: * Required
- Female
- Male
- Intersex
- Trans - Female to Male
- Trans - Male to Female
- Two-Spirit
- Other
If Other, please specify:
Sexual Orientation: * Required
- Heterosexual (Straight)
- Gay
- Lesbian
- Bisexual
- Queer
- Two-Spirit
- Other
If Other, please specify:
Current Household Composition: * Required
- Mother father child(ren)
- Couple without child
- Sole member
- Grandparent(s) with grandchild(ren)
- Extended family
- Unrelated housemates
- Siblings
- Single parent family (mother head)
- Single parent family (father head)
- Same sex couple
- Other
- Do not know
- Do not want to answer
Highest Education Level Completed:
- Primary or equivalent (grades 1-8)
- Secondary or equivalent (grades 9-12)
- Post secondary or equivalent
- Too young for primary completion
- No formal education
- Other
- Do not know
- Do not want to answer
Are you currently or have you seen a Therapist or Counsellor? * Required
- Yes
- No
Are you currently or have you seen a Psychiatrist? * Required
- Yes
- No
If Yes, please list name and year last seen:
Are you currently or have you seen any Specialists? * Required
- Yes
- No
If Yes, please list name(s) and year last seen:
Please list all medications (prescribed and over the counter).
Name Dose Directions
What is the name of the pharmacy you go to?
Do you have any of the following? Please check ALL that apply: * Required
- Diabetes
- COPD
- CHF
- Heart Disease
- High Blood Pressure
- High Cholesterol
- Arthritis
- Sleep Apnea
- Asthma
- Bipolar Disorder
- Depression
- Anxiety
- Schizophrenia
- Panic Disorder
- Psychosis
- OCD
- Dyslexia
- Alcohol Addiction
- Drug Addiction
- ADHD
- Austism
- Brain Injury
- Cerebral Palsy
- Muscular Dystrophy
- Hearing Impairment
- Vision Impairment
- None
- Do Not Know
If you have a disease, disability or disorder that was not listed above, please list below:
Your personal and medical information as documented above will be sent to the CKCHC reception team via electronic mail. * Required
- By submitting this application, I understand that electronic mail is not secure and as such, there is a risk to confidentiality.
RAPID REFERRAL
This section is to be completed by a person from an approved rapid referral organization only. *Please fill out section completely*
Referral Source:
Name: Phone Number: Ext.:
Organization:
- CKHA - MHAP
- CMHA
- ACTT
- ACCESS Open Minds
- Dr. Gopidasan (requires referral from PCP)
Name of Client's Psychiatrist:
Is your Client aware that this referral has been made?
- Yes
- No
Is your Client stable?
- Yes
- No
**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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Name	Birth Date (dd/mm/yyyy)	Health Card Number (please include version code and expiry date)	Sex	Relationship

Name	Dose	Directions

Client Application

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RAPID REFERRAL

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