Urban Rez Solutions Social Enterprise

Client Intake Form

Please fill out this form to provide us with your basic information
and how we can support your needs.

Our service standard is to review all intake forms and follow up with you within 24-48 hours of submission.

For urgent questions or support, please contact us directly:

Phone: (647) 708-7226
Email: info@urbanrezsolutions.com

    Email:*

    SECTION 1: REFERRAL INFORMATION: Please provide the details of the referring institution and or contact person.

    Institution Name:

    Referring Contact (Name):

    If no referring contact, please provide a brief explanation.

    Email:

    Contact Number:

    SECTION 2: CLIENT INFORMATION Please provide the necessary client information as follows:

    Client Name: *

    Age:

    Is the client currently in a facility?

    What is the expected exit date?

    Notes: (e.g., transition details, parole requirements, etc.):

    SECTION 3: PERSONAL CHALLENGES - DIAGNOSED CONDITIONS: Please identify any personal challenges (check all that apply):

    Substance Abuse:

    Mental Health Challenges:

    Social Isolation Concerns:

    SECTION 4: PROGRAM SUPPORT NEEDS Please select your programs needs.

    Please select the support programs that the client requires (check all that apply)*

    SECTION 5: FAMILY OR OTHER SUPPORT PERSON(S) Please provide details of family members or other support person's.

    Name:

    Relationship:

    Phone Number:

    Email:

    Please check N/A if this section is not applicable.

    SECTION 6: EMERGENCY CONTACT Please complete the emergency contact information.

    Name: *

    Relationship:

    Phone Number:

    Notes ( e.g., Best time to call, Language spoken)

    Please check N/A if this section is not applicable.

    Thank you for completing your intake form. At Urban Rez Solutions, we are committed to supporting you through this process. A case manager will be in contact with you within 24-48 hours.

    Protecting Your Information

    At Urban Rez Solutions Enterprise, our goal is to ensure your data is secure and used only for the purposes for which it was provided. We collect and handle your personal information with the utmost care, in full compliance with Canadian privacy regulations, including the Personal Information Protection and Electronic Documents Act (PIPEDA).