Client Basic Needs Form

Welcome! This form helps us understand your current situation so we can connect you with the right support. There are no right or wrong answers — please share only what you feel comfortable with. It should take about 10 minutes to complete.

Section 1 — Personal Identification

What's your full legal name?

What name do you prefer to go by?

Date of birth:

Phone number:

Email address:

Is there a safe way for us to contact you? Please describe any preferences (e.g. text only, avoid calling before 9am):

Section 2 — Housing Situation

Where are you currently staying? Select all that apply:

Renting my own place

Staying with family or friends

In a shelter or transitional housing

Living in my vehicle or outdoor space

No stable place to stay right now

Other (please describe below)

Is your current housing situation stable?

Is there anything more you would like to share about your housing situation?

Section 3 — Food Security

How would you describe your current access to food? Select all that apply:

I have regular, reliable access to food

I sometimes worry about running out of food

I have skipped meals due to lack of food or money

I currently use a food bank or community meal program

I have dietary restrictions or allergies that limit my options

Please describe any dietary needs or restrictions we should know about:

Section 4 — Health and Medical Needs

You only need to share what you feel comfortable with. This helps us connect you with appropriate health support.

Do you currently have a doctor or primary health care provider?

Yes, I have a regular doctor or clinic

No, I don't have a regular doctor

I'm not sure / I use walk-in clinics or emergency rooms

Are there any current health needs or concerns we should be aware of? (e.g. medication access, mobility, mental health support):

Do you currently have health insurance or a benefits card?

Yes

No

I'm not sure

Section 5 — Employment and Income

What best describes your current employment status? Select all that apply:

Employed full-time

Employed part-time or casual

Self-employed or freelance

Currently looking for work

Unable to work due to health or disability

Retired

Student

What are your current sources of income? Select all that apply:

Employment wages or salary

Government assistance or income support

Disability benefits

Pension or retirement income

No current income

Is there anything else about your employment or income situation you would like to share?

Section 6 — Support Network

Understanding who is already in your corner helps us build on your existing strengths.

Who do you currently have in your support network? Select all that apply:

Family members

Friends

A religious or faith community

A counsellor or mental health professional

A social worker or case manager

A community organization or support group

I feel like I do not have much of a support network right now

Is there a person we can contact on your behalf in case of an emergency? If yes, please share their name and phone number:

Is there anything else about your support network you would like to tell us?

Supporting Documents

If you have any documents that may help us understand your situation better (e.g. ID, medical letters, benefit statements), you are welcome to upload them here. This is optional.

Thank you for taking the time to fill this out. Your information is kept confidential and will only be used to connect you with the support you need. A member of our team will be in touch with you shortly.