Bridges Student Online Application

Thank you for your interest in the Bridges for Women Society.

Please choose the program you are interested in:




By now you have read and agreed to Bridges Personal Information Policy. Give yourself 20 minutes to fill in the form, then at the bottom click "submit" once. If you have a question, call toll free 1-866-896-3356. TIP: Use the Tab key to go to the next field in a section.

Last name
First name

Gender
Date of birth (yyyy-mm-dd)
Street address
City or town
Province or Territory
Postal code
Home/Primary Telephone number (including area code)
Cellular number (including area code)
Alternate number (including area code)

When is the best time to reach you?



E-mail address

Emergency contact name, relationship
Emergency contact home number (including area code)
Emergency contact work number (including area code)
 

Click on each heading below to reveal that section. When you have finished with it, you can click the checkbox (optional) to mark the section 'done.' (This feature will not work in Internet Explorer; we recommend Firefox.) Once you have filled in the full application, click 'submit' once.

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  Referral Source


How did you hear about Bridges? Check all that apply.













  Interest in Bridges


What do you hope to get out of Bridges in terms of personal growth and development? Please talk with a Bridges professional, review the brochure and website at www.bridgesforwomen.ca to answer this question.










  Personal Information


What is your current main source of income?













If you are currently receiving income assistance, do you feel you would benefit from Disability Benefits (PWD) to support a return to training, education or work?

Please indicate your disability issues in the physical and mental health sections ahead.


Have you received EI benefits in the past 3 years?

Have you received maternity benefits in the past 5 years?

What is your current marital status?
If 'Other,' please specify:
How many years together, if Married/Common-Law or living with partner?
Time out of the most recent relationship, if single?

Federal status











Aboriginal First Nation
Nationality, language, or culture other than English

  Household


What are your current living arrangements?








Do you feel this is a safe location?

May we help you find a safe location?

Is your housing affordable?
If not safe/affordable, description, and plans to change


Geographical location



  Current Family Responsibilities

List of children & other dependents


Have adequate daycare
If not, describe


Have adequate after school care
If not, describe


Single mother with special needs child
Describe, and list other individuals who assist child:


Child with health concerns
Describe physical or mental health issues and special care received:


Elder living with you with health concerns
Describe

List other family responsibilities or concerns

  Education


What is your educational background? Check all answers that apply.












If enrolled, where do you attend?
If enrolled, how many hours per week?
If enrolled, what courses or program are you taking?
What did you find hard about school?

  Technology Experience


Do you require a computer at home?

Which statements below best describe your computer-based experiences? Check all that apply.

Computer Experience:









Computer Skills
















  Employment


What is your employment status?









If employed, where do you work?
If employed, how many hours/week?
If employed, what is your gross income per hour (including tips/commissions), before taxes?

Past work experience




Past work history, check all that apply (Ministry classifications):









Describe your best best paid or most enjoyable work experience:
How many years were you in the position

How did you get along with coworkers and supervisors








  Work Goals for the Future

What type of work do you hope to be doing in the future? If you dont know, please indicate unsure at this time.

Describe any hobbies and special interests

  Impacts of Abuse on Employability


Do you feel you have barriers to employment that are related to trauma and abuse?

If yes, what presently makes it difficult for you to find or maintain employment? Check all that apply.























Why have you left jobs in the past? Please list causes (e.g. fired, quit, stress, etc.)

  Personal Development History

What are some areas that you have worked prior to coming to Bridges?

Employment training
Life skills training in parenting
Life skills training in anger management
Life skills training in communication

Therapy counselling (individual)
Therapy counselling (group)
Healing circle        
Therapy counselling (in hospital)
What place or location was therapy received?
Describe therapy history (details)


NA Self-help group
AA Self-help group
Substance misuse/addictions counselling (individual)
Substance misuse/addictions counselling (group)
Substance misuse/addictions counselling (in residence)
What place and location was counselling/treatment received?

List other personal development details (specify)


Choose the best statements to describe your overall group experiences?







  Personal Safety

For some participants who may still have contact with abusive individuals in their lives, having a safety plan in place is very important. Please comment on your current situation by answering the following questions:

QuestionCurrentlyPastExplain
I fear for my safety
I fear for my children's safety

I have a restraining order or a peace bond in place
Do you need one?
Explain:

Safety Plan







If necessary, can you commit to a break from romantic relationships while attending Bridges?

To address safe participation in the BFWOnline Program, check all that apply in the next 2 questions.

Where will you be when you participate online?







How did you choose the above?







  Personal Support System

The opinions of key people in our lives are often very important to us as we make changes in our lives. What kinds of support do you have in place in your life? How supportive is each? Check all that apply.
My 'Support System'
Minimal
support		 Some
support		 Supportive Very
Supportive		 Not
Applicable
Parents
Partner
Children
Siblings
Friends
Family Doctor
Mental Health Counsellor
Substance Misuse & Addictions Counsellors
Lawyer and/or Advocate
Other
Day care name and phone number
After school care name and phone number
Family physician's name and phone number
Therapist name and phone number
Psychiatrist name and phone number
Social worker name and phone number
Lawyer or advocate's name and phone number
List other personal supports and community resources e.g. transition shelters, community centres, computer hubs or donations:

What do the key people in your life think about you coming to Bridges?


By clicking submit, you have read and agreed to Bridges Personal Information Policy.