QELC Application Form


Client Information:

Name:

Age:

Occupation:

Telephone:

Email:

Address:


Is the client physically and mentally able to visit the clinic at 303 Bagot Street, Fifth Floor, in downtown Kingston?
YesNo

 

File Information

What would you like QELC's help with?

For the situation you’ve described above, list any people or organizations with conflicting interests (i.e. if the client is a tenant, they might have a conflict with their landlord; if they're having financial trouble they might have a conflict with creditors or the bank, etc.):

Is there a date by which this situation must be resolved?

 

Financial Information

(Please provide detailed information. This information is strictly confidential.)

Household Income:

Savings:

Real Property (house(s), cottage(s), rental property, land):

Other significant assets:

Debts:

 

How were you referred to our clinic?

Know clinic member personally.
Referred by someone. Name:
Website.
Saw clinic advertisement or brochure. Where?
Other. (please explain)


I certify the foregoing information to be accurate and complete to the best of my knowledge.