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You Belong Here Newcomer Client Intake Form

Thank you for choosing Uplift Black Centre for Social Justice and Inclusionn to support you on your settlement journey and integration into the Canadian society. This Client Intake Form is designed to help us understand your unique needs so we can provide responsive, personalized services and connect you with the right resources and opportunities.

About Uplift Black & the You Belong Here Program

Uplift Black is a Black-led organization dedicated to the upliftment, healing, and empowerment of Black communities, particularly those facing systemic barriers. One of our core programs, the You Belong Here Newcomer Program, is specially designed to support refugees, newcomers, and asylum seekers in navigating the challenges of settlement and rebuilding their lives in Canada. Through this program, Uplift Black provides practical support, community connection, and advocacy to help ensure every newcomer feels safe, seen, and valued.

By completing this intake form, you are helping us better understand your situation so that we can support you in ways that truly reflect your needs and experiences.

Objective of the Intake Process

  1. Comprehensive Records: To create and maintain an up-to-date record that enables us to offer targeted, effective support.

  2. Service Planning & Referrals: To guide the planning of programs and allow us to refer you to the most appropriate services, resources, and opportunities based on your needs.

  3. Priority Access: Clients who complete this formal intake process will be given priority for support services, including referrals, support letters, participation in events, and other activities organized by Uplift Black.

Your Voice Matters

Your input is vital. It helps us ensure our services reflect your real-life needs and that we’re planning initiatives that make a meaningful difference in your life. If you have questions or need support filling out this form, please contact us at randy@upliftblack.org

Declaration

By filling out and submitting this client intake form, I confirm that the information I have provided is true and accurate to the best of my knowledge. I understand that providing false information may affect my eligibility for services.

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1. Personal Details:

Full Name (As written on your passport)
Date of birth
MM
/
DD
/
YYYY
What is your gender?
Clear selection
What is your Sexual Orientation?
Clear selection
What is your Nationality (Country of Origin)
What is your Immigration Status (if applicable)
Clear selection
Date of Arrival to Canada
MM
/
DD
/
YYYY
2. Contact Information

Address (Include street, City, Postal Code, and Province)

Email
Phone Number 
What is your preferred method of Communication?
Clear selection
3. Language Proficiency

Languages spoken
Preferred Language of Communication

Clear selection
4. Emergency Contact

Name

Relationship to you
Emergency contact, phone number 
Emergency contact email
5. Refugee/Asylum Seeker Information (if applicable)

What is your UCI number 
6. Service Requests (please check all that apply)
If others, please explain below
Do you have a question or anything else you would like us to know?
Submit
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