This referral form is for the following programs: Tenant Support Program, Social Service Program, Veterans Homelessness Program SSW-TSW Referral Form LCC Program * Social Services program Tenant Support Program (client is resident of non-profit social housing in Thunder Bay) Veterans Homelessness Program Unsure Referral Date * Personal Information Consent obtained from individual for LCC follow-up Yes No Consent for LCC to share information with the agency that referred you? Yes No Does not apply This is not required for services and is based on your preferences Name * Household * Single (Adult) Single (Senior) Family Address * Phone * Email Date of Birth * Gender * Male Female Other Do you require a translator? * Yes No If other, please state gender identity (optional) Veteran Status Are you a Veteran? * Yes No Branch (if known) Service Number (optional) Housing Characteristics Housing Characteristics * Unsheltered - Absolutely Homeless living on the street or in places not intended for human habitation Emergency Sheltered - Staying in an overnight shelters for people homeless or impacted by family violence Provisionally Accommodated - Temporary accommodation or lacks secure tenancy At Risk of Homelessness - Not homeless, but housing situation is precarious or does not meet public health and safety standards Adequately Housed Referred By Referred by * Self Agency Other If you selected Agency / Other, please fill out the below portion: Consent for LCC to communicate with the Agency that submitted the referral Yes No Agency Name Contact Person Position / Relationship Email Phone Reason for Referral Reason for Referral * Activities of Daily Living Cultural Support Education Employment Finances Housing Legal Medical Health Mental Health Safety & Security Social Inclusion Spiritual Support Comments Submit If you are human, leave this field blank.
