Bridges Student Online Application

Thank you for your interest in the Bridges for Women Society. Bridges requires only one application per person - good for all programs. A fully completed application becomes an important "representation" of you; a tool for staff to work with in determining your present requirements.

Please give yourself 60 minutes to enter your information in full, then click "submit" once.

Application help: We realize this process may be challenging to complete in full. We recommend you call toll free at 1-866-896-3356.

Hint: Use the Tab key to go to the next field in a section.


Please choose the program you are interested in:




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.

[Show all]

  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?







  Physical Health Information

Do you currently have any of the following conditions?


N/A I am in good health

Allergy rating
List allergic reactions and emergency procedures we should know about


Chronic pain rating
Chronic pain description

Low energy rating
Low energy description

Breathing problems rating
Breathing problems description

Menstrual pain rating
Menstrual pain description

Colds and Flues rating
Colds and Flues description

Side effects of medications rating
Side effects of medications description

Walking difficulties rating
Walking difficulties description

Other rating
Other description

Are you undergoing therapy or treatment for a physical health concern, e.g. physio, chiropractor, diet
Specify, and also list any medications you are taking for physical health:


Do you require other medical supports, e.g. doctor or specialist
Specify

  Mental Health Information


Do you currently struggle with the following?
















Do you currently take medications for mental health concerns
If yes, list all medications and their purpose

List side effects

Date of your last medication review by a specialist:


Are you presently undergoing therapy for mental or emotional health, e.g. counselling, harm reduction, acupuncture?
Describe


Have you received counselling or treatment in the past
Describe


Have you ever been hospitalized for a mental health issue
Why were you in hospital

How many times have you been admitted?
Which locations were you admitted to?
What was the length of your hospital treatment?
Did you find your treatment helpful?

Are you willing to receive 10 hours of counselling as a requirement of the Bridges Program?
List the main stressers in your life at this time, and concerns you may have regarding counselling?

  Substance Misuse

Current and Past information on substance misuse, allows us to understand and provide the best support for you as you move forward with Bridges. Please fill out the information below to the best of your ability.


Do you CURRENTLY misuse drugs or alcohol to manage painful emotions or physical pain?

Drugs used









Describe how often and how much you use, and the reason e.g. to manage anxiety, to socialize:


Do you mix medications to manage pain

Do you go on and off medications
Why?


Have you misused in the PAST?

Drugs used in the past









Describe how often and how much you used, and the reason e.g. to manage anxiety, to socialize:


How long have you been clean and sober?
When was the last time you misused?
Date of Treatment Program? (yyyy-mm-dd)
Describe treatment (e.g. Methadone, AA, acupuncture) and the outcome (e.g. clean since, relapsed twice since)


Are you currently in counselling for any of the above?
Specify


Have you received counselling in the past?
Specify


Do you feel you need counselling or treatment now?
Specify


Do you have other addictions (e.g. nicotine, relationships, sex, food) that risks your food, rent, and well-being?
Explain


Are you willing to get help for this?

If you have a history of substance misuse or addictions, are you willing to commit to staying clean & sober while in a Bridges Program?

Other details or concerns regarding addictions at this time?

  Abuse History

Abuse and violence in the past or present can affect job training and employment. We would like to have some information about your experience(s). Please select all types of abuse you have experienced in your life:

Adulthood








What relationship was the abuser(s) to you?

Did you receive any counselling, community or emergency services?

Childhood








What relationship was the abuser(s) to you?

Did you receive any counselling, community or emergency services?

Date of last incident of abuse: Year Month
Remarks
Last contact with abuser
How often do you see the abuser?
Reason for continued contact
Describe the emotional effects of having contact

Have you ever used violence against another person?
Explain circumstances


If your child(ren) have also experienced abuse in some way, please check all that apply:











What relationship was the abuser(s) to your children?

Do your children have contact with the abuser?
Reason for contact:

Would you like Bridges to help you find therapy and support for your children?

  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?







  Legal Issues

Legal processes can take time and energy from you and may require that you get extra support. We would like to know what you might be dealing with while you are in a Bridges Program. Please check all that apply to you currently, including those that will apply over the next 6 months.


Divorce applies to you

Divorce experience

Divorce requires advocacy

Separation applies to you

Separation experience

Separation require advocacy

Child custody applies to you

Child custody experience

Child custody require advocacy

Ministry of children and families applies to you

Ministry of children and families experience

Ministry of children and families require advocacy

Criminal court applies to you

Criminal court experience

Criminal court require advocacy

Prison applies to you

Prison experience

Prison require advocacy

Probation appointments applies to you

Probation appointments experience

Probation appointments require advocacy

Parole applies to you

Parole experience

Parole require advocacy

Property settlement applies to you

Property settlement experience

Property settlement require advocacy

Safety orders apply to you, i.e. peace bond, restraining order

Safety orders experience

Safety orders require advocacy
Please comment:

  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?