Client Intake Form Please note that fields with the arrow down symbol ⯆ are dropdown menus.Do you need services in French?(Required) Yes No Name(Required) First Last Gender(Required)MaleFemaleOtherDate of Birth(Required) Day Month Year Country of OriginAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsNationality(Required)AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsDate 1st entered Canada Day Month Year Date 1st entered Ontario Day Month Year Province of Origin (If applicable)Not ApplicableAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonImmigration Status(Required)AIPP - Child Open Work PermitAIPP - Child Permanent ResidentAIPP - Child StudentAIPP - Child VisitorAIPP - Permanent ResidentAIPP - Pre-arrivalAIPP - Spouse Open Work PermitAIPP - Spouse Permanent ResidentAIPP - Spouse StudentAIPP - Spouse VisitorAIPP - Temporary work permit, PR in processCanadian CitizenCitizen (Aboriginal)Citizen-by-BirthConvention RefugeeHumanitarian/Compassionate Application in ProcessInternational Mobility Program WorkersJudicial ReviewLive-In CaregiverNo statusPermanent Residence Application in ProcessPermanent ResidentPre Removal Risk AssessmentProtected PersonProvincial Nominee awaiting CIC approval for PRRefugee AppealRefugee ClaimantRefused Refugee ClaimantStudentTemporary Foreign WorkerTemporary Resident Permit HolderVisitorWork Permit (Post - graduate)UnknownCanada-Ukraine Authorization for Emergency Travel (CUAET)Immigration Class/CategoryAIPPAssisted Relatives of Independent ImmigrantBusiness Class (Investor, Federal Entrepreneur, Start –Up Visa, Self-Employed)Canadian Experience ClassCaregiver PathwayDependentFamily SponsorshipFederal Skilled Trades ProgramFederal Skilled Worker ProgramHumanitarian/Compassionate Application in ProcessHumanitarian/Compassionate GroundsLive-In CaregiverOther Independent ImmigrantProvincial NomineeQuebec Selected Skilled Worker ProgramRefugee Class: Blended Sponsored RefugeeRefugee Class: Government-Assisted RefugeeRefugee Class: OtherRefugee Class: Privately-Sponsored RefugeeRefugee Class: Refugee Appeal Division (RAD)Refugee Class: Refugee ClaimantRefugee Class: Refused Refugee ClaimantStudy PermitTemporary Resident Permit (Formerly known as Minister’s Permit)Visitor (Tourist, Business Visitor, Parent and grandparent SuperVisa)Work Permit (Business People, professionals, intra-company transferees, traders, investors and migrant workers)UnknownNative Language(Required)EnglishFrenchAdaAffarAfrikaansAkaAkanAklanonAkraAlbanianAmerican Sign Language (ASL)AmharicAnuak (Anywa)ArabicAranArmenianAshantiAssyrianAzeriBambaraBantuBauleBelenBembaBengaliBeniBeninBerberBicolBijaiyaBiniBisayaBissaBontokBraille (translation only)BretonBulgarianBurmeseBusanBusangoCantoneseCatalanCebuanoChakmaChaldeanChaochoChavacanoChichewaChinese - Simplified (TRANSLATION ONLY)Chinese - Traditional (TRANSLATION ONLY)ChiuchowChiyaoChowchauConcaniCreoleCroatianCzechDanishDariDeaf-MuteDioulaDutchDzongkhaEdoEfikEstonianEweFacilitatorFangFantiFarsi (Persian)FinnishFlemishFoochowFoukiFoullahFukineseFulaniGaGaelicGeorgianGermanGreekGuerzeGujaratiHainamHakha ChinHakkaHararaHararyHargarHassanyaHausaHebrewHiligaynonHindiHindkoHokkinHungarianIbibioIboIcelandicIgorotIlicanIlongoIndonesianIshanItalianIziJapaneseJaraiJavaneseJolayKacchiKakwaKanareseKandahariKankaniKarenKashmiriKhmerKihavuKikongoKinyamulengeKinyarwandaKirundiKiswahiliKonkaniKoreanKrioKurdishLa langue des signes québécoise (LSQ)LaotianLatvianLebaneseLengieLingalaLithuanianLowmaLugandaLugishuLutoroMacedonianMacenaMacuaMahouMakondeMalagasyMalayMalayalamMaligoMalinkeMalteseMandarinMandingoMarathiMashiMendeMinaMizoMongolianMoreNepaliNorwegianNuerNzimaOkpeOriyaOromoOsalOther African languagesOther Chinese DialectsOther European languagesOther Languages NesOther Middle Eastern languagesOther Signed LanguagesOther South Asian languagesOther South East Asian languagesOther Western Hemisphere Indian languagesOtuhoPahariPampangoPashtoPeulPhuockienPidginPlautdietsch (Mennonite Low German)PolishPortuguesePoularPunjabiRohingyaRomaniRomanianRukigaRunyankoleRussianRutooroSamoanSangoScoulaSechuanSerbianSerbo-Croat-BosnianSesothoSeswiSeychellesShanShanghaiShansaiShonaSindhiSinhaleseSlovakSloveneSomaliSoninkeSothoSoussouSouthern BurunSpanishSuesueSukumaSwahiliSwazaiSwedishTagalogTaichewTamilTariTatarTatshaneseTeluguTeochewThaiTibetanTichiewTigrignaTiminiTivToishanTshilubaTsibulaTurkishTwiUdukUhroboUigrigmaUkrainianUmbunduUnamaUrduUyghurUzbekVietnameseVisayanWarayWelshWolofXhosaYiboeYiddishYorubaZshilubaZugandaZuluLanguage or Service(Required)ArabicBosnianCantoneseCroatianDariEnglishFarsi (Persian)FrenchGermanHindiKoreanLithuanianMandarinPashtoPortuguesePunjabiRomanianRussianSerbianSinhaleseSpanishTagalogTurkishUrduWere you at one point Refugee?(Required) Yes No Did you come as Sponsored by a family member Independent Immigrant Refugee Street Number(Required) Unit Street Name(Required) DirectionNot ApplicableE - EastN - NorthNE - NortheastNW - NorthwestS - SouthSE - SoutheastSW - SouthwestW - WestStreet Type(Required)ABBEY - Abbey (E)ACCESS - Access (E)ACRES - Acres (E)AIRE - Aire (E)ALLEY - Alley (E)ALLÉE - Allée (F)AUT - Autoroute (F)AV - Avenue (F)AVE - Avenue (E)BAY - Bay (E)BEACH - Beach (E)BEND - Bend (E)BLOC - Bloc (F)BLOCK - Block (E)BLVD - Boulevard (E)BOUL - Boulevard (F)BOURG - Bourg (F)BRGE - Barrage (F)BROOK - Brook (E)BYPASS - By-pass (E)BYWAY - Byway (E)C - Centre (F)CAMPUS - Campus (E)CAPE - Cape (E)CAR - Carré (F)CARREF - Carrefour (F)CDS - Cul-de-sac (E)CERCLE - Cercle (F)CH - Chemin (F)CHASE - Chase (E)CIR - Circle (E)CIRCT - Circuit (F)CLOSE - Close (E)COMMON - Common (E)CONC - Concession (E)CÔTE - Côte (F)COUR - Cour (F)COURS - Cours (F)COVE - Cove (E)CRES - Crescent (E)CREST - Crest (E)CRNRS - Corners (E)CROFT - Croft (E)CROIS - Croissant (F)CROSS - Crossing (E)CRSSRD - Crossroads (E)CRT - Court (E)CTR - Centre (E)DALE - Dale (E)DELL - Dell (E)DESSTE - Desserte (F)DIVERS - Diversion (E)DOWNS - Downs (E)DR - Drive (E)DRPASS - Droit de passage (F)ÉCH - Échangeur (F)END - End (E)ESPL - Esplanade (E)ESTATE - Estates (E)EXPY - Expressway (E)EXTEN - Extension (E)FARM - Farm (E)FIELD - Field (E)FOREST - Forest (E)FRONT - Front (E)FSR - Forest service road (E)FWY - Freeway (E)GATE - Gate (E)GDNS - Gardens (E)GLADE - Glade (E)GLEN - Glen (E)GREEN - Green (E)GRNDS - Grounds (E)GROVE - Grove (E)HARBR - Harbour (E)HAVEN - Haven (E)HEATH - Heath (E)HGHLDS - Highlands (E)HILL - Hill (E)HOLLOW - Hollow (E)HTS - Heights (E)HWY - Highway (E)ÎLE - Île (F)IMP - Impasse (F)INLET - Inlet (E)ISLAND - Island (E)KEY - Key (E)KNOLL - Knoll (E)LANDNG - Landing (E)LANE - Lane (E)LANEWY - Laneway (E)LINE - Line (E)LINK - Link (E)LKOUT - Lookout (E)LMTS - Limits (E)LOOP - Loop (E)MALL - Mall (E)MANOR - Manor (E)MAZE - Maze (E)MEADOW - Meadow (E)MEWS - Mews (E)MONTÉE - Montée (F)MOOR - Moor (E)MOUNT - Mount (E)MTN - Mountain (E)ORCH - Orchard (E)PARADE - Parade (E)PARC - Parc (F)PASS - Passage (E)PATH - Path (E)PEAK - Peak (E)PINES - Pines (E)PK - Park (E)PKY - Parkway (E)PL - Place (E)PLACE - Place (F)PLAT - Plateau (E)PLAZA - Plaza (E)POINTE - Pointe (E)PORT - Port (E)PROM - Promenade (F)PT - Point (E)PTWAY - Pathway (E)PVT - Private (E)QUAI - Quai (F)QUAY - Quay (E)RAMP - Ramp (E)RANG - Rang (F)RD - Road (E)RDPT - Rond point (F)REACH - Reach (E)RG - Range (E)RIDGE - Ridge (E)RISE - Rise (E)RLE - Ruelle (F)ROUTE - Route (F)ROW - Row (E)RTE - Route (E)RTOFWY - Right of way (E)RUE - Rue (F)RUIS - Ruisseau (F)RUN - Run (E)SECTN - Section (E)SENT - Sentier (F)SIDERD - Sideroad (E)SQ - Square (E)ST - Street (E)STROLL - Stroll (E)SUBDIV - Subdivision (E)TERR - Terrace (E)THICK - Thicket (E)TLINE - Townline (E)TOWERS - Towers (E)TRACE - Trace (E)TRAIL - Trail (E)TRNABT - Turnabout (E)TRUNK - Trunk (E)TSSE - Terrasse (F)VALE - Vale (E)VIA - Via (E)VIEW - View (E)VILLAS - Villas (E)VILLGE - Village (E)VISTA - Vista (E)VOIE - Voie (F)WALK - Walk (E)WAY - Way (E)WHARF - Wharf (E)WOOD - Wood (E)WYND - Wynd (E)City(Required) Province(Required)AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal Code(Required) Phone(Required)Email(Required) Enter Email Confirm Email Original profession or trade:00 Senior management occupations01-05 Specialized middle management occupations06 Middle management occupations in retail and wholesale trade and customer service07-09 Middle management occupations in trades, transportation, production and utility11 Professional occupations in business and finance12 Administrative and financial supervisors and administrative occupations13 Finance, insurance and related business administrative occupations14 Office support occupations15 Distribution, tracking and scheduling co-ordination occupations21 Professional occupations in natural and applied sciences22 Technical occupations related to natural and applied sciences30 Professional occupations in nursing31 Professional occupations in health (except nursing)32 Technical occupations in health34 Assisting occupations in support of health services40 Professional occupations in education services41 Professional occupations in law and social, community and government services42 Paraprofessional occupations in legal, social, community and education service43 Occupations in front-line public protection services44 Care providers and educational, legal and public protection support occupation51 Professional occupations in art and culture52 Technical occupations in art, culture, recreation and sport62 Retail sales supervisors and specialized sales occupations63 Service supervisors and specialized service occupations64 Sales representatives and salespersons - wholesale and retail trade65 Service representatives and other customer and personal services occupations66 Sales support occupations67 Service support and other service occupations, n.e.c.72 Industrial, electrical and construction trades73 Maintenance and equipment operation trades74 Other installers, repairers and servicers and material handlers75 Transport and heavy equipment operation and related maintenance occupations76 Trades helpers, construction labourers and related occupations82 Supervisors and technical occupations in natural resources, agricultural and84 Workers in natural resources, agriculture and related production86 Harvesting, landscaping and natural resources labourers92 Processing, manufacturing and utilities supervisors and central control opera94 Processing and manufacturing machine operators and related production workers95 Assemblers in manufacturing96 Labourers in processing, manufacturing and utilitiesProfession or trade you want to pursue in Canada:00 Senior management occupations01-05 Specialized middle management occupations06 Middle management occupations in retail and wholesale trade and customer service07-09 Middle management occupations in trades, transportation, production and utility11 Professional occupations in business and finance12 Administrative and financial supervisors and administrative occupations13 Finance, insurance and related business administrative occupations14 Office support occupations15 Distribution, tracking and scheduling co-ordination occupations21 Professional occupations in natural and applied sciences22 Technical occupations related to natural and applied sciences30 Professional occupations in nursing31 Professional occupations in health (except nursing)32 Technical occupations in health34 Assisting occupations in support of health services40 Professional occupations in education services41 Professional occupations in law and social, community and government services42 Paraprofessional occupations in legal, social, community and education service43 Occupations in front-line public protection services44 Care providers and educational, legal and public protection support occupation51 Professional occupations in art and culture52 Technical occupations in art, culture, recreation and sport62 Retail sales supervisors and specialized sales occupations63 Service supervisors and specialized service occupations64 Sales representatives and salespersons - wholesale and retail trade65 Service representatives and other customer and personal services occupations66 Sales support occupations67 Service support and other service occupations, n.e.c.72 Industrial, electrical and construction trades73 Maintenance and equipment operation trades74 Other installers, repairers and servicers and material handlers75 Transport and heavy equipment operation and related maintenance occupations76 Trades helpers, construction labourers and related occupations82 Supervisors and technical occupations in natural resources, agricultural and84 Workers in natural resources, agriculture and related production86 Harvesting, landscaping and natural resources labourers92 Processing, manufacturing and utilities supervisors and central control opera94 Processing and manufacturing machine operators and related production workers95 Assemblers in manufacturing96 Labourers in processing, manufacturing and utilitiesSelect the highest level of education completed:(Required)High SchoolAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOtherPrefer Not to AnswerDetails: Would you like to receive emails about HMC programs, services and events?(Required) Yes No Have you had a language (LINC) assessment?(Required) Yes No What is your LINC level?2345678n/aMarital Status(Required)SingleMarriedCommon LawDivorcedWidowedSeparatedSpouse/Partner (Full Name) Do you have any children?(Required) Yes No Please enter their names and ages (click "+" to add a row):NameAge Add RemoveHow did you hear about HMC?(Required)Community center / libraryEmployer / co-workerEthnic or religious organizationFamily / friendsIn-Canada orientation sessionCanadian government agencyGovernment publication / brochure / websiteImmigration consultant / lawyerInternal to my organizationNon-governmental Newspaper / Media / Publication / Brochure / Web SiteOther settlement service providerSchoolNot referredOverseas orientation session (e.g. CIIP)Reason for visit:(Required)HiddenSettlement Specialist Name:No Settlement SpecialistAttia AleemBushra FaisalCaren MenchavezCarole LiuCatherine LeeChristine ChenDiana BelloFunda PakelHala HalimIndu VermaIngy BebawyJaqueline BaleaJesamine PeraltaJessie ChenLeila TakeiMayda Al-YasNarmin EndrawesNeda Basri-AttarRima DeIuliisSamina RathoreSimin ShafiefarSultana ChehaibSuzan ManaaSvetlana FranzVanessa MesonesXiaoou ChenZarmina SharaniRima DeIuliisShahenda AmerDo you intend to become a Canadian Citizen?(Required) Yes No Do you give us and our funders consent to contact you for feedback about our services?(Required) Yes No Consent for Release of Information:(Required) Please check this box if you agree with the statement below.I give HMC full permission to disclose personal information to IRCC & other applicable service providers for support, guidance, advocacy, information, and referrals and upon my request for HMC follow-up and collect information from IRCC and other applicable service providers on the status of any support, guidance, advocacy, information or referrals provided to me. I consent to receive HMC services by phone, e-mail, and other online platforms when available/applicable.Signature(Required)Please sign in the space below using your mouse, finger, stylus, or touch screen pen. Would you like to receive a copy of your Intake Form submission by email? Yes No Date: 26/05/2022 PhoneThis field is for validation purposes and should be left unchanged.
