Family Name

First Name

Alias

Middle Name

What is your mother tongue?

English

French

Other

Do you require language interpretation?

Yes

No

Language you feel most comfortable speaking with your provider

English

French

Albanian

Amharic

Arabic

ASL (American Sign Language)

Bengali

Bulgarian

Burmese

Cantonese

Creole

Other Language

Czech

Dari

Farsi

Georgian

German

Greek

Gujarati

Hausa

Hebrew

Hindi

Hungarian

Italian

Karen

Korean

Kirundi

Low German

Mandarin

Nepali

Pashto

Polish

Portuguese

Punjabi

Rohingya

Romanian

Russian

Serbian

Slovak

Somali

Spanish

Swahili

Tagalog

Tamil

Do not know

Taishanese/Toishanese

Tibetan

Tigrinya

Turkish

Twi

Ukrainian

Urdu

Vietnamese

Yoruba

Prefer not to answer

Were you born in Canada?

Yes

No

Do not know

Prefer not to answer

What is your ethnic or cultural background?

Do you identity as transgender?

Yes

No

Do not know

Prefer not to answer

Are you currently employed?

Yes

No

Do not know

Prefer not to answer

Are you currently looking for work?

Yes

No

Do not know

Prefer not to answer

Is your main job temporary or part-time?

Yes

No

Do not know

Prefer not to answer

In the past 12 months, did your income change a lot from month to month?

Yes

No

Do not know

Prefer not to answer

What was your total family income before taxes last year?

$0-$19,999/Per month $0-1667/Per hour $0-$10.26/hr

$20,000-$39,999/Per month $1,668-3,333/Per hour $10.26-$20.51/hr

$40,000 -$59,999/Per month $3,334-4,999/Per hour $20.51-$30.77hr

$60,000-$79,999/Per month $5,000-6,667/Per hour $30.77-36.46/hr

$80,000-$119,999/Per month $6667-9,999/Per hour $38.46-$61.54/hr

$120,000-$149,999/Per month $10,000-$12,499/Per hour $61.54-$76.92/hr

$150,000 or more $12,500 or more $76.92 and up/hr

How many people does this income support? Include yourself + dependents

Do you feel that your current employment could be negatively affected if you raised concerned about work?

Yes

No

Do not know

Prefer not to answer

Do you identify as a person with a disability?

Yes

No

Do not know

Prefer not to answer

How would you describe your sense of belonging to your community ?( feeling of belonging, connected & accepted)

Very Weak

Somewhat Weak

Somewhat Strong

Very Strong

Do not know

Prefer not to answer

Do you feel you have people who you can open up to or confide in?

Yes I always or sometimes have someone

No I don't have anyone

Do not know

Prefer not to answer

Do you have people to rely on if you need help?

Yes I always or sometimes have someone

No I don't have anyone

Do not know

Prefer not to answer

In the past 12 months was there a time you were not able to pay the mortgage or rent on time?

Yes

No

I did not have to pay rent or mortgage

Do not know

Prefer not to answer

Please respond to the following statement-Within the last 12 months, we worried whether or food would run out before we could buy or get more

Often True

Sometimes True

Never True

Do not know

Prefer not to answer

Within the past 12 months, the food we bought just didn't last and we could not buy or get more

Often True

Sometimes True

Never True

Do not know

Prefer not to answer

In the past 12 months were you unable to get medicine or medical supplies or did you do anything to make them last longer because of the cost?

Yes

No

I do not have to get medicine or medical supplies

Do not know

Prefer not to answer

In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work or getting things needed for daily living?(Check ALL that apply)

Yes it has kept me from medical appointments or getting medicines

Yes it has kept me from non-medical meetings, appointments, work or getting things I need

Not applicable I did not need transportation for these activities in the past 12 months

No

Do not know

Prefer not to answer

In the past 12 months did you miss making a payment on any utility bills (e.g electric, gas/oil water)

Yes

No

I do not have to pay utility bills

Do not know

Prefer not to answer

Street

Apt #

City

Province

Postal code

Primary Phone *

Phone 2:

Email *

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