Submitted by bits-admin on Thu, 05/26/2022 - 11:10 First name * Last name * Preferred name What do you want the facilitator and other participants to call you? Email * Phone Number * Date of birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007 Were you referred? * Yes No Who referred you? Are you currently connected with any community supports or organizations? * Yes No What community supports or organizations are you connected with? Gender identity * - Select -FemaleMaleNon-BinaryTransgenderTwo-SpiritedUnknownPrefer not to say. Which of the following best describes you? Do you identify as 2SLGBTQIA+? * Yes No Prefer not to say. Do you identify as: * Indigenous?African Nova Scotian?A Racially Visible Person (other than Indigenous and/or African Nova Scotian)?None of the above?Prefer not to say. Choose all that apply. Do you identify as a persons with a disability? Yes No Prefer not to say. Citizenship/Immigration Status * - Select -Canadian Citizen – Born in Canada.Canadian Citizen – Born outside of Canada.RefugeeRefugee ClaimantStudent VisaWork VisaVisitor VisaUndeclaredPrefer not to say. Are you a fluent English speaker? * Yes No If no, what language(s) are you fluent in? What is your employment status? * - Select -UnemployedEmployed - Full-timeEmployed - Part-timeRetiredPrefer not to say. Veteran status * - Select -Veteran: Canadian Armed ForcesVeteran: AlliesVeteran: CivilianFormer RCMPNot a VeteranPrefer not to say. Do you have any children under 18? * Yes No If so, how many? * Number of children under the age of 18. Geographic Region * - Select -Annapolis ValleyCape BretonColchester CountyCumberland CountyDigby CountyGuysborough CountyHalifax CountyHants CountyInverness CountyKings CountyLunenburg CountyPictou CountyQueens CountyRichmond CountyShelburne CountyVictoria CountyYarmouth CountyOut of the provincePrefer not to say. Do you currently feel that your living situation is safe? * Yes No Other If you are unsure or would like to discuss your situations further, please contact the Alice on the Go facilitator. She can provide you with safety planning and further supports if needed. This can be given by verbal consent, please select ‘Other’. Do you have access to a phone/laptop or tablet device? * Phone Laptop Tablet None of the above. Check all that apply. What day/time of the week works best for the bi-weekly check-ins and virtual sessions? * What is your preferred method of communication for check-ins: * Phone Email Text Message What are you looking to gain from the Alice on the Go Program? * Anything else you'd like to share/comment/questions? Confidentiality Agreement * All components of the Alice on the Go program are confidential. In general, this means that no information is released to individuals outside the Alice on the Go program without the individual’s consent. Understand that for safety of all participants and facilitators, that any information that is shared with you must be kept in confidence while participating in the Alice on the program. This includes information such as individual’s names, number of children, addresses, and any other information that could identify the individual or breach their privacy. Understand that this information is not to be shared with anyone. By signing below, you give permission for my personal information, including any relevant Personal Health Information and Legal Information that may impact housing needs, to be collected by agencies in the Housing & Homelessness Service System and entered into the HIFIS and/ or BNL databases. I have read and understand the level of confidentially needed to participate in the Alice on the Go program and agree to maintain confidentiality. I have read and understand the level of confidentially needed to participate in the Alice on the Go program and agree to maintain confidentiality. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Enter the characters shown in the image.
