New Client Intake Form

Privacy Policy Consent Form

Bridges Niagara Privacy Policy requires that all of its employees and volunteers hold in strict confidence all information contained in a client’s file and all information acquired about a client in the course of providing service. To be able to provide service, we are required to open and maintain a file containing specific personal information. Only such information is gathered from a client as is essential for the staff to assist the client. Client files are stored in a secure manner.

In providing service to a client, the different Centre Departments may be called upon to receive or share information about the client with external agencies with which they collaborate in serving the client. The Centre staff will not share personal information about the client with such agencies without the express consent of the client.

I hereby consent to the creation of a client file in my name by the Bridges Niagara, and to the collection in that file of information about me and my family essential for the purpose of providing service to me, and in compliance with the requirements of the agencies funding the service. I understand that Bridges Niagara staff will in no circumstance contact an external agency on my behalf or about me without my express permission on each occasion. I further understand that the disclosure or exchange of information about me and/or my family to external agencies is on an as-needed basis only, for the purpose of providing service to me. I understand that I may cancel my consent at any time except for such action as has already been taken.

Do you accept our privacy policy?(Required)

Please Select

Does Bridges Niagara have your consent to contact you for future research / consultation / third party contact?(Required)

Does Bridges Niagara have your consent to contact you?(Required)

Do we have your consent to take your picture / video for the purpose of advertising on our website / social media / marketing materials?(Required)

Do we have your consent to send you promotional materials via e-mail in the future regarding programs, services, and events that may interest you?(Required)

Purpose of Appointment / Register for Event (if registering, please type event name)(Required)

Other Information Needed

First Name(Required)

Middle Name

Last Name(Required)

Gender

Self-identification

Sexual orientation

This would allow us to refer you to our in-house 2SLGBTQ services

Date of Birth(Required)

Preferred Official Language(Required)

Marital Status(Required)

Phone Number(Required)

Email Address(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is your immigration status in Canada?(Required)

Upload the corresponding ID in the last part of this form

Country of origin(Required)

Country of residence

If different from country of origin

Port of Entry into Canada(Required)

Location of where you entered into Canada (Ex. Toronto Airport, Peace Bridge, Montreal, etc.)

Arrival Date to Canada(Required)

Name of your Emergency Contact(Required)

Write down the name of the individual you would like the NFAMC to contact should you be in an emergency situation.

Emergency Contact Relationship to You(Required)

Telephone of Emergency Contact(Required)

Include the area code

Emergency Contact Relationship - 'Other'

Only answer this section if you chose 'Other". For example: cousin, partner, neighbour, boyfriend/girlfriend, common law, colleague, and any other relationship that is not listed above.

How did you hear about Bridges Niagara?(Required)

Signature(Required)

Write your full name as it appears on your government ID document

Todays Date(Required)

Mother Language(Required)

Upload your Immigration Status Government ID Documents (Front)(Required)

Max. file size: 30 MB.

For example: Refugee Claimant Document, Permanent Resident Card, Confirmation of Permanent Residence Document, Citizenship Certificate , Notice of Decision, Canadian Passport, etc.

Upload your Immigration Status Government ID Documents (Back)(Required)

Max. file size: 30 MB.

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