Canadian Mental Health Association Mid-Island - Links to Employment Self-Referral Form

Welcome to Links to Employment - Mid Island

You will receive a confirmation by email.

First name *

Last name *

Pronouns

Email *

Mobile

Gender

Health conditions Show

Important medical information

Supports in place:

REFERRAL SOURCE INFORMATION

A referring agency may complete this form to support the client in accessing Links to Employment. If so, please complete this section:

Referring Person:

Referring Person Role:

Referring Agency:

Referring Person Contact Information:

Client Aware and Consenting to Referral?

(If no, please inform the client their personal information will be shared to facilitate this referral )

Yes No

Have you been in a customized employment program like VIVRS Customized Employment program? *

NOTE: We are not a customized employment program.

Yes No

If you are receiving services, do you consent for the Links to Employment team to collaborate with your referral source? This consent will be discussed more at intake. *

Yes No

REFERRAL TO LINKS TO EMPLOYMENT:

Do you meet ALL of the following criteria? *

1. Facing health and or social barriers to employment

2. Motivation to attain meaningful employment and/or volunteer work

3. Residing within commuting distance of Nanaimo

4. Over the age of 19

Yes No

Do you identify as First Nations, Métis or Inuit?

Yes No

NEEDS ASSESSMENT:

Do you have access to the following: personal ID, means of transportation, laptop/computer, phone, bank account, housing? *

Yes No

If no, please specify your areas of need:

Are you receiving support from a local Primary Care Provider such as the Medical Arts Centre or the Nexus Primary Care Clinic? *

Yes No

If so, please specify which primary care provider:

Are you connected to other relevant health and/or social services (e.g. family doctor, social worker, counsellor.etc) *

Yes No

If so, please specify:

We may not be able to provide services if you have an open WorkSafe or ICBC claim or are accessing a wage replacement. Do you have any of these? *

Yes No

If yes, please specify when file will be closed:

RISK INFORMATION:

Is there a current concern or history of any of the following risks: harm to or from others (including children), harm to self, neglect, physical, cognitive, or memory impairment, substance misuse *

Yes No

If yes, please note a risk assessment may be required

COGNITIVE & PSYCHOSOCIAL ABILITIES *

Consistently

Occasionally

Rarely

Unsure/Unknown

Self-monitor/self-supervise

Manage deadlines and time pressures

Perform multi-tasking

Attention to detail

Work cooperatively with others

Tolerate environmental stimuli (noises/crowds/movement)

Tolerate exposure to conflict

Tolerate exposure to emotional situations/stress

Responsible and accountable

Writing Skills

Numerical Skills

Computer Literacy

Verbal Communication

Working Memory

Planning and Prioritizing

Organization

Task Initiation

Please tell us about your vocational goals (e.g., type of job, desired hours, etc.):

Please share any other information which you may think is relevant:

Completing the referral does not guarantee an intake; intakes will be screened and subject to caseload availability. Do you understand and agree to these terms? *

Yes No