APPLICATION TO GRACE HOUSE

(to be completed by applicant)


Only those accepted for an interview will be contacted.
Successful applicants will be considered for admission based upon a priority and suitability assessment, as opposed to the order in which received.

 

 

Send to: Grace House c/o 130 Cornwall Rd., Oakville L6J 7V8

 

 

NAME                                                    ADDRESS                                            TELEPHONE (H/W)

 

DATE OF BIRTH                                  PLACE OF BIRTH                         CANADIAN CITIZEN?

 

 

HEALTH CARD NUMBER                  SOCIAL INSURANCE NO.                ENTRY DATE INTO CANADA

 

REFERRING AGENCY                        ADDRESS                                            TELEPHONE

 

CONTACT PERSON                            OTHER AGENCIES INVOLVED       

1.                                                        2.                                                            3.

 

 

 

HEALTH:    

 

 

 

Medical treatment in last 2 years:

 

 

 

 

 

 

 

Psychiatric treatment in last 2 years:

 

 

 

 

 

 

 

Counselling in last 2 years:

 

 

 

 

 

 

 

Are you on  medication?

 

 

If yes, specify:

 

 

 

 

 

 

Have you had a medical examination in the last  3 months ?

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYMENT:

 

 

 

 

 

 

 

 

 

 

 

 

 

I am employed as

 

 

I am not employed 

 

 

 

 

 

 

I am able to be employed

 

 

 

Employer

 

 

I am seeking work

 

 

 

 

 

 

Type of work

 

 

 

Address

 

 

Last employment

 

 

 

 

 

 

Type of work

 

 

 

 

 

 

Length of time  

 

 

 

 

 

 

 

 

 

 

 

If you are not working, what will be your source of income while at Grace House?  

 

 

 

 

 

What arrangements have you made for pocket money?

 

 

 

 

EDUCATION:   

 

 

 

Highest grade completed:

 

 

 

 

 

If you are attending school, what program are you in and when do you expect to complete it? 

 

 

 

 

 

 

What plans do you have for furthering your education? 

 

 

 

 

 

 

 

HOBBIES AND INTERESTS:

 

 

 

How do you spend your leisure time? 

 

 

 

 

 

 

 

 

PERSONAL PROGRAM:

 

 

 

1)  What are your problems, or areas of concern, as you see them? 

 

 

 

 

 

 

 

2)  What would you like to do about them?

 

 

 

 

 

 

 

3)  How does Grace House fit into your plans?

 

 

 

 

 

 

 

4)  How do you think you would know when you are ready to leave Grace House?

 

 

 

 

 

 

 

FAMILY:

 

 

 

Marital Status:

 

 

Next of Kin:

 

 

Address:

 

Dependants (names and ages):

 

 

1)

 

 

2)

 

 

 

 

3)

 

 

4)

 

 

Relationship:

 

5)

 

 

6)

 

 

Telephone:

 

 

 

 

 

 

 

 

 

DAY PROGRAM WHILE AT GRACE HOUSE:

 

 

 

 

 

 

ADDITIONAL COMMENTS:

 

 

 

 

 

 

 

DATE:

 

SIGNATURE: