HSDE Client Intake Form

Intake Request Form

Your Personal Details

First Name(Required)

Middle Name

Last Name

Preferred/Other Name

Date of Birth(Required)

Marital Status

Gender(Required)

Level of Education

Email Address(Required)

Phone Number(Required)

Secondary Phone

Native Language(Required)

Other Spoken Languages (if applicable)

Current Residential Address

Address(Required)

Apt/Unit #

City

Province(Required)

Postal Code(Required)

Immigration Related Information

Status in Canada(Required)

UCI/IUC (Unique Client Identifier)

Country of Birth

Date of Arrival

How Did You Hear About Us

Immigration Document

This can be a Confirmation of Permanent Residence, a Work Permit, a Refugee Claimant document, a Permanent Resident Card, etc.

If uploading a Permanent Resident Card or other two-sided document, please ensure both sides are attached.

Drop files here or

Accepted file types: pdf, docx, doc, jpg, gif, tiff, Max. file size: 10 MB, Max. files: 1.

Emergency Contact Information

Full Name(Required)

Phone Number(Required)

Email(Required)

Additional Information

Which type of services are you interested in:(Required)

Would you like to provide any additional information

Details of Family Members

How many members would you like to add?(Required)

Member 1

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Status in Canada(Required)

Gender(Required)

Marital Status

Relationship(Required)

UCI/IUC (Unique Client Identifier)

Country of Birth

Country of Origin

Highest Level of Education

Total Years of Education

Preferred Method of Contact

Phone Number(Required)

Email(Required)

Consent Via Email

School Grade

School Name

Field Of Study

Member 2

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Status in Canada(Required)

Gender(Required)

Marital Status

Relationship(Required)

UCI/IUC (Unique Client Identifier)

Country of Birth

Country of Origin

Highest Level of Education

Total Years of Education

Preferred Method of Contact

Phone Number(Required)

Email(Required)

Consent Via Email

School Grade

School Name

Field Of Study

Member 3

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Status in Canada(Required)

Gender(Required)

Marital Status

Relationship(Required)

UCI/IUC (Unique Client Identifier)

Country of Birth

Country of Origin

Highest Level of Education

Total Years of Education

Preferred Method of Contact

Phone Number(Required)

Email(Required)

Consent Via Email

School Grade

School Name

Field Of Study

Member 4

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Status in Canada(Required)

Gender(Required)

Marital Status

Relationship(Required)

UCI/IUC (Unique Client Identifier)

Country of Birth

Country of Origin

Highest Level of Education

Total Years of Education

Preferred Method of Contact

Phone Number(Required)

Email(Required)

Consent Via Email

School Grade

School Name

Field Of Study

Member 5

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Status in Canada(Required)

Gender(Required)

Marital Status

Relationship(Required)

UCI/IUC (Unique Client Identifier)

Country of Birth

Country of Origin

Highest Level of Education

Total Years of Education

Preferred Method of Contact

Phone Number(Required)

Email(Required)

Consent Via Email

School Grade

School Name

Field Of Study

Member 6

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Status in Canada(Required)

Gender(Required)

Marital Status

Relationship(Required)

UCI/IUC (Unique Client Identifier)

Country of Birth

Country of Origin

Highest Level of Education

Total Years of Education

Preferred Method of Contact

Phone Number(Required)

Email(Required)

Consent Via Email

School Grade

School Name

Field Of Study

Consents and Confidentiality Statement

Purpose of Collection and Use

I consent to your organization collecting, recording, storing, and using my personal information for the purpose of providing services and communications related to events, workshops, programs, and other relevant activities. This may include administrative purposes, service coordination, follow-up communications, and internal record-keeping.

Types of Information

I understand that the personal information collected may include my name, contact details, and any other information I voluntarily provide that is necessary to deliver services or communications effectively.

Storage and Security of Information

I understand that my personal information will be stored securely and that appropriate administrative, technical, and physical safeguards will be in place to protect my data from unauthorized access, loss, misuse, or disclosure.

Sharing of Information

I consent to the sharing of my personal information with trusted third-party partners of your organization solely for the purpose of delivering services and communications as described above. I understand that such third parties are required to protect my information and use it only for authorized purposes.

Retention of Information

I understand that my personal information will be retained only for as long as necessary to fulfill the purposes for which it was collected, or as required by applicable laws or organizational policies.

Withdrawal of Consent

I am aware that I have the right to withdraw my consent at any time by contacting your organization. I understand that withdrawing consent may limit or affect the services or communications that can be provided to me.

Acknowledgement and Consent

By providing my information and/or participating in your organization’s services, events, or communications, I acknowledge that I have read, understood, and agree to the terms of this consent.

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Signature(Required)

Captcha

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Programs (Admin Only)

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Date Visited (Admin Only)

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Official Language (Admin Only)

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Current Emp Status (Admin Only)

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DOC_1 TYPE

HSDE Client Intake Form