Referral Form

386 Windmill Road, Dartmouth, Nova Scotia, B3A 1J5, Canada

Phone: 902-465-5000 Fax: 902-465-5009 Email: referral@lakecityworks.ca

Please complete all areas of this form. Incomplete form may cause delays.

LakeCity Employment Services Association is a non-profit agency that offers free employment services to people with a mental illness. We provide support for those seeking assistance with resumes, interviews, networking, skills development, work experiences, career decision making, and maintaining employment. Our service is mobile - which means that we can meet you in the community if necessary. Service is available throughout the Halifax Regional Municipality (HRM) - from Ecum Secum to Hubbards.

If you are having any trouble filling out this form please call 902-465-5000 weekdays during business hours (8:30 AM to 4:30 PM).

Name *
Name
Address *
Address
Birthdate *
Birthdate
Phone *
Phone
Income Assistance Caseworker Phone Number
Income Assistance Caseworker Phone Number
What service(s) would help you in finding/keeping employment? (Check all that apply) *
If yes, please describe:
To help you be successful at LakeCity it is important that you are connected to a community support person/agency. Please indicate if you are receiving any support from the following.
Psychiatrist Phone
Psychiatrist Phone
To help you be successful at LakeCity it is important that you are connected to a community support person/agency. Please indicate if you are receiving any support from the following.
Family Doctor Phone
Family Doctor Phone
To help you be successful at LakeCity it is important that you are connected to a community support person/agency. Please indicate if you are receiving any support from the following.
Other Community Support Phone
Other Community Support Phone
Other Employment Agency Phone
Other Employment Agency Phone