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The form supports intake into Client Intervention and Support Services (CISS), Family Support Services (FSS), and Housing Support Services, outlining program descriptions and household eligibility requirements. A dedicated consent section explains collection, use, and sharing of personal and personal health information, electronic communication risks, voluntary consent, and consent management options. It also records consent type, date, and the person providing consent.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/community-partnerships-and-support-services-intake-form-consent-and-client-information/306973/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/community-partnerships-and-support-services-intake-form-consent-and-client-information/306973.png","ImageObject",442,249,{"name":88,"@type":89},"Mali","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is collected in the intake form’s general section?","Question",{"text":109,"@type":110},"The form gathers the person completing the form’s name, the date of referral, referral source, referral contact email and phone, and the program(s) being referred for, including selected program details.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What does the consent section cover?",{"text":114,"@type":110},"The consent section explains how the Region seeks your agreement to collect, use, and share your personal and personal health information to determine eligibility and support service planning and navigation for listed support services or programs.",{"name":116,"@type":107,"acceptedAnswer":117},"Can consent be changed or withdrawn?",{"text":118,"@type":110},"Yes. 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Housing Access Unit Rent Supplement Program Agency/Other (please specify):\u003Cbr>Referral Contact Email: Referral Contact Phone: |\n| Service/Program Being Referred to: Client Intervention and Support Services (CISS)\u003Cbr>Family Support Services\u003Cbr>Housing Support Services Social Worker |\n\n\n| SECTION 2 –COMMUNITY PARTNERSHIPS AND SUPPORT SERVICES PROGRAM INFORMATION |  |  |  |\n| --- | --- | --- | --- |\n| Program Name | Description | Household Eligibility |  |\n| Client Intervention & Support Services (CISS) | York Region’s Client Intervention and Support Services Program (CISS) can help older adults delay or avoid placement in long-term care by providing in-home assessments, case management, counselling, referrals, psychoeducation, and support advocating for a client’s needs | Households must:\u003Cbr>• Live in York Region\u003Cbr>• Not live in long-term care\u003Cbr>• Be 60 years of age or over\u003Cbr>• Consent to service |  |\n| Family Support Worker (FSW) | Helps households with financial literacy training, income benefits system navigation, financial assessments, and education | Households must:\u003Cbr>• Live in York Region\u003Cbr>• Not receive Ontario Works\u003Cbr>• Have financial or program navigation concerns\u003Cbr>• Consent to service |  |\n| Housing Support Services\u003Cbr>(HSS) | Provides households with Social Worker supports that offer psycho-social assessments, case management, supportive counselling, referrals, and advocacy when managing situations,\u003Cbr>such as:\u003Cbr>• Mental health concerns\u003Cbr>• Complex family dynamics\u003Cbr>• Tenant conflict\u003Cbr>• System navigation\u003Cbr>• Eviction prevention\u003Cbr>• Hoarding, clutter, housekeeping | Households must:\u003Cbr>• Reside in a Housing York Inc. building\u003Cbr>• Consent to service and participate in service plans |  |\n|  |  |  |  |\n\n23-2056 HOUSING SERVICES Page 1 of 6  \nCOMMUNITY PARTNERSHIPS AND SUPPORT SERVICES INTAKE FORM  \nSECTION 2 – CONSENT  \nTo help you remain stably housed, The Regional Municipality of York (the “Region”) is seeking your consent to collect, use, and share the personal information and personal health information contained in this form and its attachments (together, the “information”) with representatives of the Region’s Community and Health Services Department. Sharing means that we will disclose your information to representatives of the Region’s Community and Health Services Department, and collect and use your information from those representatives. We will only collect, use, and share your information with representatives of the Region’s Community and Health Services Department for the purposes of determining your eligibility for services, and to assist in service planning and service navigation with respect to the following Support Services or Programs:  \n• Client Intervention and Support Services (CISS)  \n• Family Support Services (FSS)  \n• Social Worker/Housing Support Services  \nAs the Region must share your information with the Community and Health Services Department to determine your eligibility for services, we will not be able to process your intake without your consent to share your information.  \nWe will store your information in a secure database, and may use electronic communication, such as email or fax, to communicate your information to representatives of the Region’s Community and Health Services Department. Electronic communication is not guaranteed to be secure. Some privacy risks include messages being intercepted by others in transit, and messages accidentally being sent to the wrong email address or fax number. In providing this consent, you accept ","cbCairnV57FYFXaK","https://ap.wps.com/l/cbCairnV57FYFXaK","pdf",402795,6,"English","# SECTION 1 – GENERAL INFORMATION\n# SECTION 2 – CONSENT\n# SECTION 3 – CLIENT INFORMATION","[{\"question\":\"What information is collected in the intake form’s general section?\",\"answer\":\"The form gathers the person completing the form’s name, the date of referral, referral source, referral contact email and phone, and the program(s) being referred for, including selected program details.\"},{\"question\":\"What does the consent section cover?\",\"answer\":\"The consent section explains how the Region seeks your agreement to collect, use, and share your personal and personal health information to determine eligibility and support service planning and navigation for listed support services or programs.\"},{\"question\":\"Can consent be changed or withdrawn?\",\"answer\":\"Yes. The decision is voluntary, preferences can be changed, and consent can be withdrawn at any time by notifying the Region; information already shared with consent would not be impacted.\"}]","COMMUNITY PARTNERSHIPS AND SUPPORT SERVICES INTAKE FORM - Consent and Client Information | PDF",1789842759]