Halifax By-Name List Intake Form - PERSONAL INFORMATION - First Name Last Name Alias

Halifax Coordinated access manual 1 Halifax By-Name List Intake Form (To be completed by staff and client together) PERSONAL INFORMATION First Name Last Name Alias Date of birth: Age: What is your pronoun? Do you identify as transgender or non-binary? ☐ Yes ☐ No Are you a member of the LGBTQ2 community? ☐ Yes ☐ No Are you Indigenous? ☐ Yes ☐ No Are you of African Descent? ☐ Yes ☐ No Have you ever. [...] ✓ I understand that the following agencies will have access to my information on the By-Name List for the purpose of adding my name and updating my status: ☐ Adsum for Women and Children ☐ Salvation Army Centre of Hope ☐ Shelter Nova Scotia ☐ Out of the Cold Shelter ☐ Affordable Housing Association of Nova Scotia (AHANS) ☐ Other: (specify) ✓ I understand that I can request to have my name removed. [...] Which of the following are your preferences for housing? ● Independent apartment? ☐ Yes ☐ No ● Shared accommodations or rooming house? ☐ Yes ☐ No ● Supportive housing? ☐ Yes ☐ No 2. [...] What are your preferences for an apartment? ● Size of building? ☐ small ☐ medium ☐ large ● What are your preferred neighbourhood(s)? (Check all that apply) ☐ North End Halifax ☐ North End Dartmouth ☐ South End Halifax ☐ Cole Harbour ☐ Fairview ☐ Other (please specify:) ☐ Clayton Park ___________________________ ☐ Downtown Dartmouth ● On which floor would you prefer to live? ☐ Ground, ☐ Basement, ☐. [...] What else is important for you with regards to your housing? ● Close to a grocery store? ☐ Yes ☐ No ● Close to a pharmacy? ☐ Yes ☐ No ● On a bus route? ☐ Yes ☐ No ● Power included? ☐ Yes ☐ No 5 ● Internet and/or cable included? ☐ Yes ☐ No Support preferences 1.