BRIDGING HORIZONS: NEEDS ASSESSMENT FORM

BRIDGING HORIZONS: NEEDS ASSESSMENT

Client’s Name:

Assessment Date:

Case Worker (full name)

Client's DOB:

Age:

Part 1: CLIENT INTAKE

Support Services

(Will they require any support services to access the referrals they receive following this assessment?)

Child Care

Yes

Transportation

Yes

Provisions for persons with disabilities (ASL interpretation, screen readers, etc)

Yes

Written Translation

Yes

Oral Interpretation

Yes

Digital Supports to access IRCC-funded settlement services remotely - skills & devices

Yes

Short Term Counselling

Yes

Client Intake

Unique Client Identifier (UCI)

Contribution Agreement

Preferred Official Language

Assessment Delivery Format

Postal Code where the service was received (if virtual, please insert the postal code of the SPO delivering the service

Do you need a training session or other assistance to make sure you are comfortable navigating a remote settlement service or using a device to access remote settlement services?

Yes

Type of service location, Institution/Organization where client received services

Client Information

Legal First and Last Name

Preferred Name

Gender (optional)

Country of Birth/Country of Citizenship

Date of arrival in Canada

Marital Status

Spouse/Partner's:

Name:

Date of Arrival:

Date of Birth:

Gender:

Languages:

1st Child:

Name:

Date of Arrival:

Date of Birth:

Gender:

Languages:

2nd Child:

Name:

Date of Arrival:

Date of Birth:

Gender:

Languages:

3rd Child:

Name:

Date of Arrival:

Date of Birth:

Gender:

Languages:

4th Child:

Name:

Date of Arrival:

Date of Birth:

Gender:

Languages:

5th Child:

Name:

Date of Arrival:

Date of Birth:

Gender:

Languages:

Have you completed NAARS before?

Yes

Do you have an existing settlement plan?

Yes

Number of NAARS completed?

Are you currently receiving settlement services from any other Service Provider Organizations?

Yes

Name of Organization(s) and Program

Contact Information

Do you provide consent to be contacted?

Yes

What is the best way to contact you (phone, email, Whatsapp etc...)

Do you have an email address?

Yes

What is your e-mail?

Do you have a phone number?

Yes

Is your phone textable?

Yes

What is your phone number?

Do you have an emergency contact in Canada?

Yes

Emergency contact name?

Emergency contact phone number?

Emergency contact relationship to you?

What is your current address?

Guiding Questions

Do you have an emergency contact in Canada?

Yes

What are your settlement objectives?

Are there resources or services that you would like to access immediately?

Yes

Do you have any friends, extended family members or people you know already in your new community?

Yes

What is your 1st settlement priorities

What is your 2nd settlement priorities

What is your 3rd settlement priorities

Part 2: CLIENT ASSESSMENT - Basic Needs

(Does the newcomer indicate that they require assistance with basic needs?)

Are you connected to any other services that can help you get settled in Canada? If yes, which ones?

Yes

Provided Service

Do you require additional clothing?

Yes

Do you require any personal care items or childcare products?

Yes

Do you require any assistance acquiring food?

Yes

Do you need additional supplies for you or your family?

Yes

Do you have any urgent medical concerns at this moment?

Yes

Are you comfortable with the use of technology (for example, are you comfortable: using a mobile device, computer, or tablet; searching for information online, downloading and using mobile apps, etc.)?

Yes

Do you have access to a tablet or computer that can be used to access services?

Yes

Do you have access to the internet or Wi-Fi?

Yes

. Do you need help with managing and scheduling appointments?

Yes

Do you need help filling out forms or letters?

Yes

Do you feel safe and secure at home? (This question requires sensitivity and may require asking individuals separately for safety, as per policies on violence/abuse

Yes

Would you like to be connected with services that can help you with mental heath and well-being?

Yes

Do you need help navigating the local transit systems and commuting in your settlement city? (Public transport, car travel, biking, etc.)

Yes

Do you require any help regarding your current housing situation?

Yes

Do you or any of your family have any needs or personal circumstances we should be aware of that may impact your temporary or permanent accommodation requirements

Yes

Language and Literacy(All clients must be asked language-related questions)

Francophone services are available within this community. Would you like to receive settlement services in ?

French offered by a francophone organization

English offered by an anglophone organization

Which other language(s) do you speak? Specify the language

Are you able to read and write in your own language(s)?

Yes

Did you complete a language assessment in Canada?

Yes

CLB/ESL Level?

Do you want to schedule a Language Assessment?

Yes

Are you interested in language training in class with a teacher or any other similar types of formal language learning?

through conversation circles/groups, homework clubs, peer support groups, writing workshops or any other kind of similar informal language learning

in class with a teacher or any other similar types of formal language learning? (Note: French-speaking newcomers and allophones settling in Francophone minority communities (FMCs) are eligible to adapted language training (a combination or sequencing of English and French language instruction)

Would you like to attend formal language learning in English or French?

Are you interested in language learning ?

Yes

Would you like to attend formal language learning in English or French?

Employment, Education and Career Training

Do you have previous work Experience in Canada?

Yes

How many months or years?

Would you like to learn more about working in Canada? (ex: labour laws, employee rights and responsibilities, occupational health and safety, Workplace Hazardous Materials Information System codes of conduct, etc.)

Yes

Select what you want to learn

labour laws

employee rights and responsibilities

occupational health and safety

Workplace Hazardous Materials

information System codes of conduct

Other

What is your Employment Status?

Would you like to obtain employment within one year?

Yes

Do you need information on how to find employment?

Yes

Do you need assistance or supports with finding employment (e.g. job counselling, training program, work placement)?

Yes

Do you need assistance or supports with finding employment (e.g. job counselling, training program, work placement)?

Yes

Do you need help drafting a cover letter, resume, help with interview skills, e.t.c?

Yes

Would you like to be connected to an informal career mentor?

Yes

Would you like to be connected to volunteer opportunities?

Yes

What are your employment objectives?

Do you know the type of work you would like to do?

What was/were your previous occupation(s)?

How many years were you in your profession/or at your workplace?

Do you require credential recognition or are you seeking to obtain a licence to work in Canada?

Yes

Would you like help beginning this process?

Yes

Would you like help beginning this process?

Yes

Do you need an Education Credential Assessment to assist with employment (indicates Canadian equivalency) or to continue pursuit of education?

Yes

Do you require help with foreign qualification or credential recognition to work in a regulated occupation or trade?

Yes

Do you have specialized skills or volunteer experience that could help you to find work, or that could otherwise be an asset to your community?

Yes

Please specify the industry of your specialized skills and/or your volunteer experience (For example: Health, Agriculture, Gardening, Horticulture, Cooking, Carpentry, Lumber industry, Oil industry, Volunteering, Early education teaching skills, Special education skills, etc.)

Do you require help with starting a business?

Yes

. Do you have any specialized training? Or have you worked in a regulated occupation/trade?

Yes

. Do you have any specialized training? Or have you worked in a regulated occupation/trade?

Yes

Are you interested by work that does not require formal education (agriculture, manual labour, kitchen, etc.)?

Yes

What is your Level of Education?

In which country did you receive your credentials?

Have your credentials been evaluated in Canada?

Yes

What country were your credentials evalauated?

Yes

In which country did you receive your credentials?

Do you have any incomplete formal education?

Yes

How many years have you completed and in which field?

What educational objectives do you have?

Are you interested in continuing or upgrading your education in Canada?

Yes

Do you require information on education? (Programs, courses, etc.)

Yes

Do you require information for applying to student aid?

Yes

Do you need any other employment support?

Yes

Family and Children

Do you require help enrolling your children in school?

Yes

Do you need help enrolling your children that are younger than 5 years old to a kindergarten or to pre-school?

Yes

Do you have a school preference for your children/youth?

Yes

Do your children require education in a special needs establishment?

Yes

Do your children require assistance with sign language in their school?

Yes

Would you prefer your children to attend school in French, in English or in French immersion at an English school?

Do you need help with your children’s online learning, should online learning be required? Should online learning be required, would you require assistance?

Yes

Would your children benefit from a referral to the Settlement Workers in Schools (SWIS) program (if available and not already provided)?

Yes

Would you like to learn more about SWIS?

Yes

Would you like to be referred to francophone SWIS (travailleur d’établissement dans les écoles - TEE)?

Yes

Do you need an afterschool program for your children?

Yes

Do you require assistance communicating with school staff?

Yes

Do you require information about school clubs/activities?

Yes

Are you aware of children/youth community programming?

Yes

Do you require information about youth activities, or afterschool & weekend programs, such as: sports and recreational activities; volunteering; leadership programs; home-work clubs; etc.?

Yes

Are your children displaying behavioral issues or being victim of bullying?

Yes

Do your children (and do you) feel safe and secure at school and at home? (*This question requires sensitivity and may require asking individuals separately for safety, as per policies on violence/abuse)

Yes

Would you like to be referred to resources or services to assist with challenges you are experiencing in your family related to behaviours, mental health, addictions, well-being, relationships, legal or safety concerns?

Yes

Government Services, Finances, and Legal Aid

Does the client require help obtaining any of the following:

Social Insurance Number

Driver’s licence

Application for provincial resident card

PR card (or a change of address, requiring a new PR card)

Senior Benefits

Canada Child Benefit

GST/PST rebate

Provincial Health Card

Interim Federal Health program

Initial health check up

Services and funding for children with disabilities

Disability benefits, support/programming

Tax credits from CRA

Application for affordable housing

None of the above

Is this a pre-arrival assessment?

If the newcomer is receiving this assessment in pre-arrival (before they arrive in Canada), would they like to receive help determining where in Canada they would like to settle?

Yes

Do you require help understanding the governmental supports available to you?

Yes

Do you intend to become a Canadian Citizen?

Yes

Unsure

Would you like to learn more about

life in Canada

the Canadian Government

the Canadian education system

the Canadian legal system

legal aid

community legal clinics

your immigration status and legal documents

Would you like to be referred to Information and Orientation Services:

Yes

Do you require information on finances in Canada?

Opening a bank account

Using a bank card

Paying rent and utility bills

Mobile and internet banking services

Loans, debt, credit, mortgages in Canada

Would you like to gain more knowledge in financial literacy?

Do you wish to be referred to Social Assistance programs?

Other

Social Supports and Community Connections

Which linguistic community Do you wish to be connected to?

Do you require information on cultural activities or other ways to get involved in your/a community?

Yes

Would you like to be connected to community groups within your community?

Yes

Do you have any hobbies or interests that may help you to find groups with shared experiences? please specify

Would you like to be connected with other newcomers in Canada?

Yes

Which community group do you want to refer to? (such as personal / topic)

seniors

women

youth

+2SLGBTQIA+

persons with disabilities

relationships

childcare

parenting

occupation-specific

professional networks

addressing abuse

dealing with financial concerns

Would you be interested inbeing connected with a Canadian friend/volunteer or established immigrant for additional support?

Yes

Would you be interested inbeing connected with a mentorship program?

Yes

Do you have any preferences on the type of mentorship program? please specify

Would you be interested inbeing connected with a religious/ethno-cultural community in Canada?

Yes

Have you experienced any instances of discrimination or racism in any of the following environments since arriving in Canada?

Yes

Would you like to be connected with supports that can help you to address these challenges? (Discrimination is the unfair treatment of a person or group of people based on the groups, classes, or other categories to which they belong. Reasons for discrimination include, but are not limited to: a person’s race, gender, religion, nationality, ethnicity (culture), or other personal traits)

Yes

Where would you like to be connected?

In a work environment (in interviews or with colleagues)

In school, or in the child(ren)’s school (by teachers or peers, administrators)

In housing (in finding housing or in shared living accommodations)

In settlement services (in any immigration organization)

In the community (stranger, police, etc.)

Other

Do you need any services for other people in your family?

Yes

Please detail:

First Name

Last Name

Date of Birth:

Phone Number

Relationship to You

Assets

Certifications

Yes

Computer and Technical skills

Yes

Creative/artistic skills (i.e. music, art, etc.)

Yes

Customer service experience

Yes

Education

Yes

Employment

Yes

Entrepreneurial skills

Yes

Family and home organizational skills

Yes

Finance and investment skills

Yes

Interpersonal skills

Yes

Leadership skills

Yes

Management skills

Yes

Organizational skills

Yes

Social capital (friends/family/support system)

Yes

Administrative skills

Yes

Language skills

Yes

Other Communication Skills (e.g. ASL) - please specify

Valid Drivers License?

Yes

More specialized assets or skills

Health

Agriculture

Gardening

Horticulture

Cooking

Carpentry

Lumber industry

Oil industry

Volunteering

Early education teaching skills

Special education skills

Other

Other Assets - please specify

Part 3: REFERRALS TO CASE MANAGEMENT ELIGIBILITY ASSESSMENT

Class 1 Indicators

Knowledge of English/French

Knowledge in First Language of the Newcomer

Education

Employment Skills

Previous Living Conditions

Social Supports in Canada

Family Size

Settling in Canada

Class 1 Total

Class 2 Indicators

Health

Diasability

Advocacy

Mental Health and Wellbeing

Personal/Familial Safety

Congruent or Incongruent

CLASS 2 TOTAL

TOTAL of CLASS 1 and CLASS 2 Indicators

Notes