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Settlement Intake Form

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)

Date of Birth(Required)

Day

Month

Year

Country of Origin

Nationality(Required)

Date 1st entered Canada

Day

Month

Year

Date 1st entered Ontario

Day

Month

Year

Province of Origin (If applicable)

Immigration Status(Required)

Immigration Class/Category

Native Language(Required)

Language or Service(Required)

Were 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)

Direction

Street Type(Required)

City(Required)

Province(Required)

Postal Code(Required)

Phone(Required)

Email(Required)

Enter Email Confirm Email

Original profession or trade:

Profession or trade you want to pursue in Canada:

Select the highest level of education completed:(Required)

Details:

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?

Marital Status(Required)

Spouse/Partner (Full Name)

Do you have any children?(Required)

Yes

No

Please enter their names and ages (click "+" to add a row):

Name

Age

How did you hear about HMC?(Required)

Reason for visit:(Required)

Hidden

Settlement Specialist Name:

Do 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: 07/10/2022

Name

This field is for validation purposes and should be left unchanged.

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Services
Training
Events
Resources
About Us
Donate
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News
Support for Ukrainians

One Community for All

Head Office

1092 Speers Rd.
Oakville, ON L6L 2X4

North Oakville

380 Dundas St. E. Unit #11
Oakville, ON L6H 6Z9

Burlington

Burlington Centre
777 Guelph Line, Unit 204
Burlington, ON L7R 3N2

Milton

55 Ontario St. S. Unit #A3
Milton, ON L9T 2M3

Georgetown

360 Guelph St. Unit #33
Georgetown, ON L7G 4B5

Call us at 905-842-2486

STAY CONNECTED

© 2022 Halton Multicultural Council. All Rights Reserved. For information or inquiries please contact info@haltonmc.com.

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