The Learning Kitchen Project Referral Form

(To be completed by the referring agent) Attention: Robert Lundrigan Email: learningkitchen@feednovascotia.ca Phone: (902) 464-3031 Fax: (902) 464-3024

Release of Information Authorization:

I, __________________________________, agree to be referred to the Learning Kitchen Project, and therefore agree that _________________________________, the agency or professional making the referral, can release information from my file that is relevant to my acceptance into the program. Applicant Signature: _____________________________________ Date: _________________

Applicant Information:
Full Name: Address: Application Date: Telephone: Alternate #

SIN #

E-mail Address:

Client Income Sources: Please check all that apply

C Currently on EI or eligible for EI? Employed Social Assistance Disability Income

EDP Other

Support Systems:
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Type: Family Support Child Care Supports Home Supports Referring Agency Supports Other (specify)

Yes / No:

Explain:

Challenges / Impairments:
Type: Physical Challenges Visual Impairment Speech Impairment Substance Abuse Other: Yes / No: Type: Deafness Mental Illness Intellectual Challenges Learning Disability Other: Yes / No:

Comments / Behavioural Concerns:

Please provide information regarding applicants behaviour and affect that may be relevant:

Referring Agent Information:

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Name and Position: Agency: Address: Telephone: Email: Relationship to Applicant: Length of Involvement With Applicant: Fax:

Reason for Referral: Applicant Initiated _____ Worker Initiated _____

Physical Requirements:
The Learning Kitchen Project is labour intense and involves extensive physical work on a daily basis, including, lifting up to 50 lbs and standing on your feet all day. To your knowledge, will this applicant be able to complete the physical requirements of the program? Yes _____ No _____

Referring Agents Assessment:

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This section should only be completed if referral source is a professional in the field of Mental Health, Physical Health or Social Services. Skill Level of motivation Social skills development Insight into own skill level Ability to deal with stress Ability to interact with others Ability to handle authority Ability to concentrate on tasks Ability to conceptualize Ability to take responsibility for self Excellent Good Fair

What is your professional assessment of this individuals readiness to participate in this employment-training program?

Please provide any additional information you feel may be relevant:

Signature: _________________________________________ Date: _____________________