Service Disruption Notice
Service Disruption Notice
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Service Disruption Notice
Service Disruption Notice
English
English
Français
Home
About Us
About The Chatham-Kent Community Health Centres
Our Healthcare Team
FAQ’s
History of the CKCHC
The Board of Directors
Accessibility
Privacy
Strategic Plan
Multi-Sector Service Accountability Agreement
Annual Reports
Quality Improvement
News
Resources
Galleries
Programs & Services
Online Booking
Age Well
Breathe Well
Cardiac Rehabilitation & Secondary Prevention
Dietitian Services
Eating Disorders
Health Promotion / Wellness Programs
Low German
Mental Health & Addictions
Outreach
Primary Health Care
Telemedicine
Traditional Healing
Youth
Get Involved
Donate
Client Experience Survey
Join Our Team
Student Placements
Thank a Staff Member
Volunteer
Events
Show All Events
Chatham Events
Wallaceburg Events
Walpole Island Events
Contact Us
Contact Us
Client Application
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Client Application
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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
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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**
We would love to hear from you!
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