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 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 Submit If you are human, leave this field blank.
