2. 
4. Welcome

   This form includes a full listing of the support services, and programs that are available to individuals and families living in Chestermere and South East Rocky View that are delivered by the City of Chestermere's Community Support Services (CSS) team, or in partnership with local agencies.

   INSTRUCTIONS: To complete our General Intake Form please fill in your information in the fields below, followed by the topics/areas of support that you would like to be contacted about. All questions with an asterisk * are mandatory.

   Once you have completed this form you can hand deliver it with your printed supporting documents to the address below OR submit this form via email to csinfo@chestermere.ca and someone from our department will respond to you within 2 business days.

   Please note that all information contained in this form is kept strictly confidential.

   Mailing/hand-delivery address:
    Chestermere Community Support Services
    105 Marina Road
    Chestermere AB T1X 1V7
   A secure drop box is located on the right side of the main south doors.

6. CONTACT INFORMATION
8. Did you know?

   This form can be translated into over 100 different languages. Look for the small Google pop-up on the bottom right-hand side of your screen and select the language you would like by clicking "Select a Language".

10. First Name*
11. Last Name*
13. Primary Phone Number*
14. Email Address*
15. City or Town of Residence*
17. How would you like us to contact you?*

    1. Phone
    2. Email
18. When is the best time for us to contact you?*

    1. Weekday mornings
    2. Weekday afternoons
    3. Weekday evenings
20. I provide my consent to allow Community Support Services (CSS) team members to share my information internally with another team member, when deemed appropriate.*

    1. Yes
    2. No

    By providing your consent to the statement above, you are giving permission for a CSS team member to share your information internally with another team member. This is done to ensure that you receive the most relevant program and service information. 

    Please note that your consent will expire one year from the date you submit this form.

24. Family & Community Resource Centre (FCRC) Supports:

    The Family & Community Resource Centre (FCRC) provides free and confidential services to Chestermere and South East Rocky View individuals and families. 

    This includes but is not limited to assistance with basic needs support and information and referrals to local supports and resources. Please indicate the topics/areas of support that you would like to be contacted about from the list below (select as many as you would like):

    1. *Financial Support
    2. Financial Literacy Workshops & Classes
    3. Assistance with Accessing Government Support Programs (i.e. special needs support, unemployment, etc.)
    4. *Community Access Program (CAP): access to subsidized services for eligible candidates (i.e. recreational activities, income tax completion, etc.)
    5. Other (please provide more information in the field below)

    1. *Transit Subsidy (i.e. public or school transportation)
    2. Basic Needs Support Referrals (i.e. food supports, clothing, shelter information, etc.)
    3. Community Referrals (i.e. household items, training programs, career and employment, etc.)
    4. Counselling & Mental Health Supports (i.e. low cost and free counselling options, multilingual counselling, support groups, etc.)
    5. Information & Resources for Newcomers & Immigrants
26. If you selected 'OTHER', please provide us with more information:
28. Family & Community Support Services (FCSS)

    The Family & Community Support Services (FCSS) team provides community development initiatives to individuals and families in Chestermere & Southeast Rocky View.

    Please select the topics/areas of support that you would like to be contacted about from the list below (select as many as you would like):

    1. Urban & Rural Community Garden(s)
    2. Neighbourhood Block Parties (general information)
    3. Programs, Information, and Supports for Older Adults
    4. Human Services Advisory Board Grants (i.e. Vitality, FCSS, and United Way)
29. 

    CLICK HERE to complete our form to host your own Block Party.

31. If you selected one or more of the following programs or supports:

    1. Financial Supports, 2. Community Access Program (CAP), OR 3. Transit Subsidy, please note that we require that you provide us with specific documents to help determine your eligibility for the service/program. 

    Please proceed to the next step - INCOME VERIFICATION DOCUMENTS - FILE ATTACHMENT.

    
    

33. Income Verification Documents - File Upload

    Please print or email a copy or photo of one of each of the following document types and include them as an attachment to your completed intake form:

    1. PROOF OF IDENTITY DOCUMENTS: This type of document confirms your identity and must show your photo, full legal name, and date of birth. This can include one of the following documents: a copy (photo) of a Government-issued Driver's License, Passport ID page, or Alberta Registration Card.

    2. PROOF OF INCOME DOCUMENTS: This type of document must contain your full name, address and have a date of less than 90 days to ensure the information is reasonably current. This can include a copy of one of the following documents: Notice of Assessment from the Canada Revenue Agency (CRA), a benefits statement from Assured Income for Severely Handicapped (AISH), a Learner Income Support (formerly Alberta Works) statement, a statement from a Seniors Financial Assistance program, or a letter from a Registered Social Worker (RSW).  

35. Parent & Caregiver Support Services (PCSS) & Chestermere/Strathmore Family Resource Network (FRN):

    Parent & Caregiver Support Services (PCSS) offers free, universal parenting support and educational programs for parents/caregivers with children ages 0-13. We are part of the Chestermere/Strathmore Family Resource Network (FRN) which also provides free early childhood development and youth programming for families and children ages 0-18 years of age.

    Please select the topics/areas of support that you would like to be contacted about from the list below (select as many as you would like):

    1. One-on-One Parenting Support
    2. Online Developmental Check-Ups (Ages & Stages Questionnaires)
    3. Early Childhood Development Programs (i.e. play-based groups, early literacy groups, etc.)
    4. Parenting Workshops & Programs (Positive Parenting Program, Kids Have Stress Too, etc.)

    1. General Parenting Information & Resources (i.e. potty training, disobedience, etc.)
    2. Youth Programs
    3. Community Referrals (i.e. Speech & Language Pathologist, children or youth with special needs, etc.)
    4. Other
37. If you selected 'OTHER', please provide us with more information:
41. Are you a City of Chestermere staff member or a local Service Provider who is assisting or completing this form on behalf of a client?*

    1. Yes
    2. No
42. If yes, which of the following options best describes your role:

    1. City of Chestermere Staff Member
    2. Community Support Services (CSS) Staff Member
    3. Local Service Provider
    4. Other
44. If you selected 'OTHER', please describe your role:
45. Name & Phone Number of Individual Helping or Completing this Intake Form:

    We will contact you if we have any additional questions.

46. Client and/or Resident Notes

    Please include any important notes or details that you feel are important for the Community Support Services (CSS) team to be aware of.

50. Freedom of Information & Privacy (FOIP)

    Your personal information is being collected for activities related to the City’s Community Support Services programming and/or activities and as such is deemed to be an activity of the City of Chestermere. The personal information is collected under the authority of Section 33(1)c of the Freedom of Information and Protection of Privacy Act and will be used only for the purpose identified. If you have any questions or concerns about the collection or use of information you may contact the FOIP Coordinator at City Hall, 105 Marina Road, Chestermere, AB T1X 1V7 or call (403) 207-7050.

Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field