Online Application

Online Application for Services

Thank you for your interest in applying for services from Next Step Residential Services.

To maintain our level of standards, our intake process is designed to ensure that the level of service required is compatible with our current caseload.

Please note: Your SIN number will be required to complete your application. You can provide confidential details by phone or in person.

Step 1 of 11

Personal Details:

Name(Required)

First Last

Email(Required)

Main Phone Number:(Required)

Secondary Phone Number:

Address(Required)

Street Address Address Line 2 City Province Postal Code

Age:

Date of Birth:(Required)

MM slash DD slash YYYY

Gender:(Required)

Female

Male

Transgender

Non-binary

Prefer not to say

Alberta Health Card Number(Required)

AISH Number

Guardianship and Family Contacts

Guardian:(Required)

Name

Phone

Address

Self/Private/Public/Partial?

Parents:(Required)

Name

Phone

Address

Contact? (Yes/No)

Trustee:(Required)

Name

Phone

Address

Self/Private/Public/Small T?

Medical Information:

Please list all medical professionals below:

Doctor, Dentist, Optometrist, Pharmacist, Psychiatrist, Psychologist, Neurologist, other. Use the PLUS + sign on the right to add additional contacts.

Name:

Phone:

Please list any allergies:(Required)

Please list all current medications:(Required)

Use the PLUS + sign on the right to add additional medications.

Name:

Dose:

Time(s):

Nature of Disability or Formal Diagnosis:(Required)

Date diagnosed and doctor, if possible.

Background/History:(Required)

Family, medical, previous/current agencies, etc.

Mobility concerns:(Required)

Major surgeries:(Required)

Adaptive Aids/Technology:(Required)

Ability to communicate health concerns:(Required)

Ability to make decisions regarding healthcare:(Required)

Medication delivery (independent, assisted, etc.):(Required)

Individual’s ability to complete tasks:

Telling time:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Toileting:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Awareness of personal hygiene:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Washing hands and face:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Bathing:(Required)

Getting in and out of bathtub or shower.

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Shampooing and conditioning hair:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Combing hair:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Brushing teeth:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Shaving (face, legs, etc.):(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Menstrual care:

(If applicable)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Dressing and undressing:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Cutting fingernails and toenails:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Hot/cold determination:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Sleeping Patterns/Routines:(Required)

Typical bed and wake times, nighttime concerns, etc.

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Transportation:(Required)

Method, independence, etc.

Communication:(Required)

Verbal, picture exchange, sign language, etc.

Personal Supports:(Required)

Comment on behaviours in social settings, personal relationships, etc.

Academic:

Level of Education:(Required)

Writing:(Required)

Proficient	Competent	Neutral	Limited ability	Incompetent

Numeracy Skills:(Required)

Proficient	Competent	Neutral	Limited ability	Incompetent

Finances

Funding Secured:(Required)

Yes

Funding Source:(Required)

PDD

Other

Personal Income Source:(Required)

AISH

Work

Other

Individual’s level of comprehension:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Who handles the individual's finances?:(Required)

Residential Skills

Individual’s ability to plan and prepare meals:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Grocery Shopping:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Personal Shopping:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Telephone Skills:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Safety

Individual’s ability to respond to emergency situations.

Fire Safety:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

First Aid:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Poison/Cleaners:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Road Safety:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Recognizes Danger:(Required)

Highly capable	Moderately capable	Neutral	Limited ability	Completely Incapable

Recreation and Leisure

Identify any activities, hobbies, cultural, etc:(Required)

Individual’s ability to access the community:(Required)

Awareness of surroundings and independence in the community.

Comment on any work skills, work experience, volunteering or employment goals:(Required)

Behavior and Abilities

Individual’s areas of strength:(Required)

Areas of concern:(Required)

Sensory, money management, home living skills, anger management, self-regulation, etc.

Behaviours of concern:(Required)

Use the PLUS + sign on the right to add additional behaviours.

Describe Behaviour:

Where/when behaviour occurs:

Frequency and cause/triggers:

Strategies: (what has been tried and has it been successful?)

Please comment on any item not previously discussed that may be significant:

Name of person filling out report:

First Last

Relationship to Applicant:

Consent(Required)

By submitting this online application form, I acknowledge that I am seeking services from Next Step Residential Services Ltd. to assist with my support needs. I consent to participate in the intake assessment process, which may involve the collection and use of personal information relevant to my disability, support preferences, and goals. I understand that the information provided will be used solely for the purpose of delivering and improving services tailored to my needs. I also understand that I have the right to withdraw my consent at any time, although this may impact the provider’s ability to offer appropriate support services.

I agree.

I understand that Next Step Residential Services Ltd. is committed to maintaining the privacy and confidentiality of my personal information. I acknowledge that all information provided in this application form will be treated with the utmost confidentiality and will only be accessible to authorized personnel involved directly in my care. I agree that my personal information may be shared with third-party service providers, such as healthcare professionals or government agencies, as necessary for the provision of comprehensive support services. I also understand that Next Step Residential Services Ltd. employs industry-standard security measures to protect my personal information from unauthorized access, disclosure, alteration, or destruction. If I have any concerns or questions regarding the privacy of my information, I understand that I can contact Next Step Residential Services Ltd. for further clarification.

I agree to the privacy policy.