Living in Community Application Form

Client Information

Before you start the below application form, please print this Release Form and complete it. You can then upload it to the below application or send it to us via fax or mail.


Have you participated in this program before?
 Yes    No

Do you consume any nonprescribed drugs or alcohol?
 Yes    No

Emergency Contact Information

By submitting this form, you agree that if the SSNS deems a situation to be an emergency that we have your permission to contact your emergency contact listed on these forms.

Social Worker/Community Support Worker Contact Information


Clinical Contact Information

The Schizophrenia Society of Nova Scotia requests that you grant us permission to discuss your wellness with your medical team. The Schizophrenia Society requires this information as we need a confirmed diagnosis to be eligible for this program. In addition to requiring a confirmed diagnosis we need to be able to communicate with your medical team in order to support you completely. We request that all residents complete the Capital Health Medical Release form.

Financial Information and Employment


Income assistance


Independent Living Skills Survey

On a scale of 1 to 10 please circle where you feel your level of competency is, 1 being no skills at all and 10 being highly proficient.

Attending Appointments:
Taking Medications Regularly:
Paying Bills:
Grocery Shopping:

Please print this Release Form and complete it. You can then upload it below or send it to us via fax or mail.

 Enter the text you see:
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