Full Name: / Intake Date:
Peer Support person completing the intake: / Contact minutes completing intake:
Referral Source: (Where did you hear about us?)
What is your experience with mental illness?
What are your recovery goals? What do want achieve by attending OSH? (Tick boxes)
☐Socialization
☐Life Skills
☐Support Groups
☐Self-Care / ☐Peer Support
☐Community Engagement
☐Volunteer Work
☐Other:
What programs or activities would you attend?
☐Diagnostic Specific Groups (such as Mood Disorder)
☐Mindfulness Group
☐Crafts
☐Budgeting
☐Assertiveness
☐Photography
☐Community Helper Presentations
☐Cards/Games
☐Walking Group / ☐Self-Care Info Session
☐Anger Management
☐Family Support Groups
☐Concurrent Disorder Groups
☐Laughter Therapy
☐Book Club
☐ Yoga or other wellness activity
☐ Trips
☐ Other:
Are there any barriers to attending programming at OSH?
Are you interested in 1:1 peer support? (explain Peer Support) Yes☐ No ☐
What would your goals be for peer support?
Are you interested in volunteering or sharing a skill or hobby with others? Yes☐ No ☐
If YES, please give details:
What is Membership?
We would like everyone to feel a sense of belonging in being a member Oxford Self Help. We strive to providea non-judgemental, accepting and supportive space.
Part of membership includes being able to give your feedback and suggestions on the types of programs you would like to see offered. We are open to ideas around where we can grow and enhance what is available. We encourage you to participate in the planning and organizing of programs and activities in areas where you have a passion or skill to share with others. Please let us know if you would like to get involved.
The statement below describes our view of how our relationship exists.
Statement of Mutual Respect
As staff, volunteers and persons receiving services at Oxford Self Help, we commit ourselves to providing a safe, healthy, secure and respectful environment through the prevention of violent, abusive and aggressive behaviour or language.
“Harassment means engaging in a course of vexatious comment or conduct against a person that is known or ought reasonably to be known to be unwelcome, including sexual harassment of any sort.” (Ontario Human Rights Commission)
Illegal activities of any kind are prohibited in the building and are not tolerated. If we believe that an individual may be under the influence, they will be asked to leave and will be able to return when they are not high. Police will be notified if illegal activity is witnessed.
OSH focuses on Recovery-oriented practices and services that support the recovery journey. This is done by “working to create genuine partnerships between service providers, service users, families, and supporters that are based on respect for the expertise gained through lived experience as well as professional expertise.” (MHCC, Strategic Direction)
Persons unwilling to adhere to this statement and its responsibilities will face actions ranging from verbal discussions, up to and including being banned permanently from the premise.