APPLICATION FOR SERVICES
YORKTON BRANCH
PARTNERS IN EMPLOYMENT
222 Smith Street
Yorkton, Sask S3N3S6
PHONE: (306) 782-0023
FAX: (306) 782-6967
MISSION STATEMENT
The Saskatchewan Abilities Council works with people of varying
abilities to enhance their independence and participation in the
community through vocational, rehabilitation and recreational services.
I, , hereby authorize the SASKATCHEWAN
ABILITIES COUNCIL to obtain or release any relevant information concerning myself that
will aid in rehabilitation planning on my behalf.
Date:
D M YSignature of Applicant or Legal Guardian
PERSONAL INFORMATION (PLEASE PRINT)
Applicant’s name: ______Phone No.: ______
Address: ______Postal Code: ______
Birthdate: ______Age: ______Marital Status: ______
D M Y
Gender: ______Citizenship: ______Dependents: ______
Social Insurance No.: ______Personal Health No.:______
Next of Kin/Family Contact: ______Relationship:______
Address: ______Phone No.:______
Living Arrangement: (i.e. independent, family, boarding home, etc.)______
Method of Transportation: ______
Driver’s License No.: ______Class: ______
Physician: ______Phone No.:______
Optional: Please check if any of the following apply:
First Nations Metis Inuit Non-Status Indian
Band Affiliation: ______Treaty No.: ______
Disability If yes, please explain: ______
Visible Minority
REFERRAL SOURCE (who told you about our service?)
Name: ______Position: ______
Agency: ______Phone: ______
Address: ______Date: ______
D M Y
Frequency of contact: ______
Reason for referral: ______
Service(s) requested from the Saskatchewan Abilities Council:
Vocational Evaluation Supported Employment Training Centre
ABI Supported Employment ABI Community Support Life Enrichment
Activity Centre Other (if other, please explain) ______
OTHER AGENCY INVOLVEMENT (Do you have support from other organizations?)
1) Name of Agency: ______Phone No.: ______
Who do you work with there?:______Date of last contact: ______
D M Y
What do they do for you?: ______
2) Name of Agency: ______Phone No.: ______
Who do you work with there?:______Date of last contact: ______
D M Y
What do they do for you?: ______
Have you ever been admitted to or involved with any of the following type of organizations?
rehabilitation centre
psychiatric treatment program
correctional facility
other (if other, please explain) ______
Please provide information on any behaviours that may put yourself or others at risk (i.e. substance abuse, anger management issues). Please specify.
______
______
Are there any legal issues pending for you, i.e. litigation? Yes No
If yes, please specify: ______
______
______FINANCIAL INFORMATION
Are you currently receiving: Social Assistance Employment Insurance
Long Term Disability Canada Pension Other______
(please specify)
Name of Income Security Worker, if applicable: ______
Telephone No.: ______Amount: ______
How long have you been receiving social assistance benefits? ______
Do you have a financial trustee: Yes No
If yes, please list name:______Phone no.: ______
Are you involved with any public or private insurance companies such as SGI, WCB?
Yes No If yes, which one: ______
If you don’t have an income, how do you meet your financial needs? ______
______
EDUCATION AND TRAINING (Start with most recent)
Grade/Course/Program: School/Institution: Location: Dates: Outcome:
CURRENT EMPLOYMENT STATUS (please check one of the following)
Employed full-time Employed part-time Retired
Unemployed Training Centre Student
Volunteer Homemaker Self Employed
Other (if other, please explain) ______
What do you consider your barriers to employment to be? ______
EMPLOYMENT HISTORY (please list most recent jobs)
1) Job Title: ______Wage: ______/hour
Employer: ______Start of Employment: ______
Immediate Supervisor: ______End of Employment: ______
Address: ______Telephone No.: ______
Part Time Full Time Seasonal Casual Self-Employed
Was this: Paid Employment Work Experience Volunteer Training-on-the-job
Reason for leaving: ______
2) Job Title: ______Wage: ______/hour
Employer: ______Start of Employment: ______
Immediate Supervisor: ______End of Employment: ______
Address: ______Telephone No.: ______
Part Time Full Time Seasonal Casual Self-Employed
Was this: Paid Employment Work Experience Volunteer Training-on-the-job
Reason for leaving: ______
3) Job Title: ______Wage: ______/hour
Employer: ______Start of Employment: ______
Immediate Supervisor: ______End of Employment: ______
Address: ______Telephone No.: ______
Part Time Full Time Seasonal Casual Self-Employed
Was this: Paid Employment Work Experience Volunteer Training-on-the-job
Reason for leaving: ______
AREAS OF CONCERN FOR ACTIVE PROGRAM PARTICIPATION
Please check all that apply:
PHYSICALCOGNITIVEPSYCHO-SOCIAL
speech memory fatigue
vision concentration awareness of injury
hearing slowed thinking restlessness
sensation attention inability to cope
headaches communication relating to others
co-ordination reading mood swings
muscle tone writing agitation/frustration
seizures planning motivation
endurance/stamina sequencing depression
appearance judgment anxiety
hygiene emotional control
allergies anger management
GOALS
What are your goals? ______
______
How do you feel the Saskatchewan Abilities Council can assist you to achieve your goals?
______
______
______Date: ______
Name of person completing this form D M Y
The information in this document is true and accurate:
______Date: ______
Client Signature D M Y
Policy 40.20.110 – 5 of 7 Revised July 2004
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