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Eligibility Screening Form

Please answer the following questions to assist us in identifying appropriate services.

All clients’ personal information is kept confidential according to our Privacy Policy.

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Applicant Name(Required)

Address(Required)

Street Address City Province

Phone Number

Gender(Required)

How Did You Hear About Us?

Community Organization, Settlement Services, Other Social Service Providers

Government Agencies (school district, Ministry of Social Development, Municipality)

Promotional Material / Website

Friends / Family

Walk In / Other / Self Refer

Additional Notes

Comments

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

Healing begins when we know and acknowledge where we are located. EMPOW3R acknowledges that the land and waters we are settled, as the traditional, ancestral, and unceded territories of the Coast Salish people; xʷməθkwəy̓əm (Musqueam), Skwxwú7mesh (Squamish), and Səl̓ílwətaʔ/Selilwitulh (Tsleil-Waututh) Nations. We heal as a community!

Breaking The Cycle Of Trauma: develop career goals, build employability skills, increase self reliance, and participate in community

EMPOW3R

P: +1 604-254-5401
E: empow3r@kiwassa.ca
A: 2425 Oxford Street Vancouver BC V5K 1M7

Eligibility Screening Form

Tell us more about yourself

Please tick YES or NO

1. What is your RESIDENCY STATUS? Please Check One

2. Are you receiving government funding? Please check one that is applicable to your situation.

3. Are you employed, underemployed, or precariously employed?

4. Other Information

5. Childcare Needs

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