Service User Application Form

General Information

First Name*

Last Name*

Preferred Name

Date of Birth (DD/MM/YYYY)*

Home Address*

City*

Province*

Postal Code*

Home Phone Number*

Cell Number

E-mail

Primary Contact*

Relationship

Phone Number*

E-mail

Secondary Contact

Relationship

Phone Number

E-mail

Community Services Worker*

Phone Number*

Fax Number

E-mail

Residential Agency

Contact Person

Res. Agency Phone Number

E-mail

Public Trustee/SDM

Phone Number

Medical Information

Allergies

MHSC # (6-digit number)

Manitoba PHID (9-digit number)

Doctor

Phone Number

Self-Administered Medications (and other medications we need to be aware of in case of anemergency)

Method of Transportation to and from ImagineAbility

Preferred Start Date with ImagineAbility support services

1. What do you expect to get from ImagineAbilities services?

2. What do you expect from ImagineAbility staff?

3. Where have you worked/volunteered? (other day programs, job placements, volunteer experience)

4. What did you like about your previous jobs?

5. What did you like about your previous support staff?

6. What did you dislike about previous jobs?

7. What did you dislike about previous support staff?

8. What are some of the things you love to do at work?

9. What do you love to do outside of work? At home? On the weekend?

10. What are some of the things you dislike at work?

11. What would you like to learn more about? (Work skills, hobbies, interests, experiences...)

12. What are 5 things you would like to achieve/experience at Imagineability?