SSW-TSW Referral Form Referral Date * LCC Program * Social Services Tenant Support (client is resident of non-profit social housing in Thunder Bay) Unsure Referred by * Self Agency / Other Consent obtained from individual for LCC follow-up Yes No If you selected Agency / Other, please fill out the below portion: Agency Name Contact Person Position Email Phone Client Information Name * Date of Birth * Household * Single (Adult) Single (Senior) Family Address * Email Phone * Gender * Male Female Other If other, please state gender identity (optional) Do you require a translator? * Yes No Do you have a physical disability or require an assistive devices? * Physical disability Assistive devices Yes for both Neither Are you indigenous? * Yes No If yes, which First Nations Community? Reason for Referral * Abuse/Safety/Dealing with Violence Accessibility Issues Addictions/Alcohol or Drug Concerns Income Support (annual verification, budgeting, banking, etc.) Increase Social Connections Advocacy (medical, legal, etc.) Literacy/Translation Support Assistance with Forms & Referrals Pest Issues Tenancy Mediation Daily Living Assistance (cooking, cleaning, grocery, etc.) Food Security Homeless Health Concerns Risk of Homelessness Comments Consent for LCC to communicate with the Agency that submitted the referral * I Agree Submit If you are human, leave this field blank.
