1. Applicant Information First Name Last Name Middle Name(s) Date of Birth Phone Number Email Preferred Contact Method Phone Email Current Address City/Town Postal Code 2. Family Information Please list all family members who would be participating: Family Member 1 First Name Last Name Middle Name(s) Date of Birth Relationship Will Attend? Yes No Family Member 2 First Name Last Name Middle Name(s) Date of Birth Relationship Will Attend? Yes No Family Member 3 First Name Last Name Middle Name(s) Date of Birth Relationship Will Attend? Yes No Family Member 4 First Name Last Name Middle Name(s) Date of Birth Relationship Will Attend? Yes No Are there children in your care? Yes No If no, please share 3. Cultural Identity & Connection (Optional) Nation/Community/Background Languages Spoken Treaty/Status Number (optional) What type of cultural supports are you seeking while residing here? 4. Referral Information How did you hear about Kahkiyaw Healing Haven? Self-referral Community organization Child & Family Services Other Name of Referral Person Organization/Agency Phone Number Email Address 5. Worker / Support Person Information (if applicable) Do you currently have a worker or support person? Yes No Worker Name Role/Title Organization/Agency Phone Number Email Address Is this worker involved in your participation here? Yes No May we contact this worker if needed? Yes No 6. Reason for Application What is bringing you to Kahkiyaw Healing Haven at this time? What are you hoping will change or improve for your family? 7. Current Situation Are you currently involved with any of the following? Child & Family Services Court processes Counselling or treatment programs Other support Are there any conditions, plans, or requirements we should be aware of? 8. Medical & Wellness Information (Confidential) This information helps us provide safe and supportive care for your family. Does anyone have medical conditions we should be aware of? Yes No If yes, please describe Medications (name, dosage, schedule) Allergies (food, medication, environmental) Mental health or emotional wellness supports needed (optional) Mobility, accessibility, or physical support needs 9. Alberta Health Care Information (Confidential) If you are from Saskatchewan, please use the same format. Name on Health Card Alberta Health Care Number (PHN) Name on Health Card Alberta Health Care Number (PHN) Name on Health Card Alberta Health Care Number (PHN) Name on Health Card Alberta Health Care Number (PHN) 10. Emergency & Medical Contact Primary Care Provider (optional) Emergency Contact Name Relationship Phone Number 11. Readiness & Participation Why do you feel ready to participate in this program? Are you willing to participate in: Family healing circles Cultural teachings and activities One-on-one support sessions Group programming Is there anything that may impact your participation? 12. Safety & Support Needs Are there any safety concerns we should be aware of? Yes No If yes, please describe 13. Goals & Commitment What are your goals for your time at Kahkiyaw Healing Haven? How will you support your family’s healing during this time? 14. Consent & Agreement By signing below, I acknowledge that: I am applying to participate in Kahkiyaw Healing Haven programming. I understand participation requires respect, honesty, and commitment. I agree to engage in a safe and respectful way with others. I consent to sharing personal and medical information for care and coordination purposes. Full Name Date Save registration Clear form Your progress will appear here.
Kahkiyaw Healing Haven
Kahkiyaw Healing Haven