HTML Preview Case Management Client Intake Form page number 1.
Client Intake Form (A)
Person Information
Gender: Female ♀ Male ♂ Other
Birthdate (dd/mm/yyyy):___________________
Last Name: ___________________________________________
First Name: _________________________________________
Social Insurance Number: _____________________________
Email Address: ________________________________________
Phone Number: ___________________________________________
Marital Status: Single Married Common-Law Widowed
Service Language: English French
Divorced Separated Other
Mailing Address:
Street Address: ______________________________________________________________________________________________
City:__________________________________
Province: ___________________________
Postal Code: ________________
Registration Details:
Employment Status:
Self - Employed
Seasonal Employment
Unemployed
Full-time Employed
Part-time Employed
Variable Hours
Are you legally entitled to work in Canada? Yes No
Are you a student?: Full-time Part-time No
What is your preferred correspondence method?
Regular Post Email Telephone
COLLECTION, USE, & DISCLOSURE OF PERSONAL INFORMATION
The Nova Scotia Government Labour Market Programs provided by the Departments of Labour and Advanced Education; Community Services,
and the Office of Immigration, are bound by the principles and requirements of the Nova Scotia Freedom of Information and Protection of
Privacy (FOIPOP) Act. The FOIPOP Act defines the meaning of personal information; in addition to the information defined by the Act, other
types of personal information may include: date of birth, Internet Protocol address, e-mail address, or other information collected by our
programs or services.
The personal information collected will only be used and disclosed in keeping with the access and privacy provisions of the Nova Scotia FOIPOP
Act and the Nova Scotia Personal Information International Disclosure Protection (PIIDA) Act. Any personal information collected during the
course of accessing our programs or using our services is used only for providing you with services; for example, for registration to our programs
or for determining your eligibility to services etc.
We do not disclose your personal information to other organizations or individuals except as required to fulfill the purpose(s) of the program or
service and only to the extent required or authorized by law.
Some functions within these programs or services are provided by service providers external to the department(s). All external service providers
that provide you with services on our behalf must comply with our privacy requirements and must meet the applicable security, privacy and
terms of use provisions.
Under the privacy provisions of the FOIPOP Act individuals have the right to correction of, and access to, their personal information. To obtain
access or request correction of your personal information please contact the Information Access and Privacy Services unit by email at
IAPServices@novascotia.ca or phone (902) 424-2985 or 1-844-424-2985.
I acknowledge that I have read and understand the above information regarding the collection, use, and disclosure of my personal information:
Client name [ please print ]
Client signature
Date (dd/mm/yyyy)