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Repairs
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Full Name
Date of Birth
Gender
Male
Female
Prefer not to say
Other
Phone Number
Email Address
Referral Source
Self
Local
Council
Referring Organization
Referral Contact Person
Current Housing Situation
Homeless
Temporary Housing
Supported Accommodation
Living with Family/Friends
Renting (Private)
Social Housing
Other
Support Type Needed
Supported
Non-Supported
Previous Supportive Housing Experience
Children or Dependents (Yes/No
Yes
No
Specific Needs for Dependents
Physical Health Concerns
Chronic Illness
Mobility Limitations
Respiratory Issues (e.g., Asthma)
Chronic Pain
Diabetes
Heart Conditions
Hearing Impairment
Visual Impairment
Epilepsy or Seizure Disorder
Autoimmune Disorders
Mental Health Support Needs
Anxiety
Depression
Post-Traumatic Stress Disorder (PTSD)
Bipolar Disorder
Schizophrenia
Obsessive-Compulsive Disorder (OCD)
Substance Use Disorder
Eating Disorder
Attention-Deficit/Hyperactivity Disorder (ADHD)
Panic Disorder
Current Health Services
Accessibility Needs
Current Employment Status
Employed Full-Time
Employed Part-Time
Self-Employed
Unemployed
Student
Retired
On Disability Benefits
Homemaker
Looking for Work
Not Seeking Employment
Education Level
No Formal Education
Primary School
Some High School
High School Diploma or Equivalent
Some College
Vocational/Technical Certificate
Associate Degree
Bachelor’s Degree
Master’s Degree
Doctoral or Professional Degree
Support Needed
Resume Building
Job Training
Interview Preparation
Financial Literacy
Time Management
Computer Skills
Conflict Resolution
Language Skills (e.g., English as a Second Language)
Career Counseling
Personal Development Workshops
Primary Goals with BNA Housing CIC
Secure Permanent Housing
Improve Physical Health
Enhance Mental Health and Wellbeing
Gain Employment
Develop Financial Stability
Access Educational Opportunities
Build Job Skills and Training
Increase Self-Sufficiency
Strengthen Social Connections and Support
Improve Daily Life Skills (e.g., cooking, budgeting)
Interest in Community Engagement
Yes
No
Support Preference
One-on-One
Group
Both
Emergency Contact Name
Relationship to You
Phone Number
Alternate Phone Number
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