Halifax By-Name List Intake Form PERSONAL INFORMATION

I understand that the following information will be added to the By-Name List: ● My name, date of birth and all information on the By-Name List Intake Form ● My current housing situation ● My contact information ● My VI-SPDAT assessment ● Any other relevant information to assist in my housing placement I understand that non-profit housing providers and housing support providers will be forward. [...] 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 ☐ Upper ● Do you prefer your ow. [...] 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 ● Internet and/or cable included? ☐ Yes ☐ No 5 Support preferences 1. [...] I understand that if I have questions about this consent form, I can contact: at I have read or have had this read to me and understand all the parts of this consent form and give consent.