CARMIS Smart Forms

Client Intake Form

"*" indicates required fields

Your Personal Details

First Name*

Middle Name

Last Name

Preferred/Other Name

Date of Birth*

Marital Status*

Gender*

Level of Education

Email Address*

Phone Number*

Secondary Phone

Preferred Language*

Other Spoken Languages (if applicable)

Current Residential Address

Address*

Apt/Unit #

City

Province*

Postal Code*

Immigration Related Information

Status in Canada*

UCI/IUC (Unique Client Identifier)*

UCI/IUC (Unique Client Identifier)

Country of Birth

Date of Arrival

How Did You Hear About Us

Emergency Contact Information

Full Name*

Phone Number*

Email*

Services

Which type of services are you interested in:*

Would you like to provide any additional information

Details of Family Members

Would you like to register your family members so that they can also receive services with us?

Yes

How many members would you like to add?*

Member 1

First Name (Member 1)*

Last Name (Member 1)

UCI/IUC (Unique Client Identifier) (Member 1)

Date of Birth (Member 1)*

Relation with you*

Gender (Member 1)*

Member 2

First Name (Member 2)*

Last Name (Member 2)*

UCI/IUC (Unique Client Identifier) (Member 2)

Date of Birth (Member 2)*

Relationship (Member 2)*

Gender (Member 2)*

Member 3

First Name (Member 3)*

Last Name (Member 3)*

UCI/IUC (Unique Client Identifier) (Member 3)

Date of Birth (Member 3)*

Relationship (Member 3)*

Gender (Member 3)*

Member 4

First Name (Member 4)*

Last Name (Member 4)*

UCI/IUC (Unique Client Identifier) (Member 4)

Date of Birth (Member 4)*

Relationship (Member 4)*

Gender (Member 4)*

Member 5

First Name (Member 5)*

Last Name (Member 5)*

UCI/IUC (Unique Client Identifier) (Member 5)

Date of Birth (Member 5)*

Relationship (Member 5)*

Gender (Member 5)*

Member 6

First Name (Member 6)*

Last Name (Member 6)*

UCI/IUC (Unique Client Identifier) (Member 6)

Date of Birth (Member 6)*

Relationship (Member 6)*

Gender (Member 6)*

Consents and Confidentiality Statement

Mail Consent

I consent to be added to the mailing list for information on events and workshops.

The Agency protects personal information by following the government's privacy laws as outlined in the Personal Information Act, Bill 38: http://www.leg.bc.ca/37th4th/3rd_read/gov38-3.htm

Staff will not disclose any information without client permission unless legally obligated to do so. Completion and submission of this intake form implies consent to collecting information for these purposes.

By signing below and submitting this form, you confirm that you have read the Gathering Information statement and has given consent to future Immigration, Refugees, and Citizenship Canada Research/Consultation.

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