The ASK Wellness Society would like to acknowledge that our programs and facilities operate on Secwepemcúl'ecw, Nłeʔkepmx Tmíxʷ, and Syilx tmixʷ traditional and unceded territories.

Stollery Suites on Spirit Square Housing Application

Please fill out the following form to complete your application for Stollery Suites on Spirit Square. Please take your time and ensure that all information is entered correctly. Fields with an * are required to be filled out.

Household Information

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Medical Information


Daily Living


Is assistance required in the following areas?

Parole


Is assistance required in the following areas?

Probation


Is assistance required in the following areas?

Home Health


Is assistance required in the following areas?

Other


Is assistance required in the following areas?

Other


Financial Information

Please complete the following related to your Financial Situation.

SELF


Financial Information

Please complete the following related to your Financial Situation.

CO-APPLICANT


Statement of Confidentiality

ASK Wellness Society (ASK) provides a wide range of services in both individual and group settings. The most important way we ca keep our ASK community safe is to maintain trust. This is done by keeping all ASK matter in the strictest confidence. Therefore, no participant of ASK shall disclose any information; spoken or written; which refers to any members of our ASK Community (clients or staff) Information regarding your involvement with ASK is confidential and protected; however, there are exceptions to our confidentiality where it would be necessary to report specific information. This could include the following situations. • If we become aware that children are being neglected or abused; • If we become aware that a client may do serious harm to themselves or others; • If we have information that would facilitate treatment of a medical emergency; and/or • If an ASK staff member is subpoenaed to court.


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