Interested Resident - Kind Minds House
Please fill in the information as accurately and honestly as you can. This form will allow us to determine if you, or the resident you are filling this form on behalf of would be a good fit in the first Kind Minds House. We will contact you with more information once we receive your response.
Sign in to Google to save your progress. Learn more
Email *
First & Last Name of Resident *
Phone Number of resident (XXX-XXX-XXXX) *
Name of Parent or GuardianĀ  *
Phone number of parent or guardian (XXX-XXX-XXXX) *
Parent or guardian email *
Sex of Resident *
Age of Resident *
Can the resident be alone overnight? *
Please select all the activities the resident can engage in independently. *
Required
Can they engage in their daily routine with a minimum of 2 hours support daily? *
Do they want to live more independently? *
Can they cooperate with others? *
Does this resident have a behaviour safety plan? *
Do they have an intellectual disability? *
Do they have a physical disability? *
Do they have any ADLs (Aids of daily living)? *
Does the resident work or are they in school? *
When would the resident be ready to move in? *
MM
/
DD
/
YYYY
Is there any additional information you can share about your resident? *
Why does the resident, or care taker want the resident to live in the Kind Minds House? *
Why do you think they would be a good fit for the Kind Minds House? *
Do they receive government funding? *
Are they interested in pooling funds with the other residents for shared support outside of the times offered by Kind Minds *
Do they require connection to an agent who can help them apply for government funding? *
I understand that Kind Minds will contact me using the email provided above to discuss the above mentioned residents eligibility for the Kind Minds House. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy