administration office 101 worthington street east … forms/2017/70d3b2b… · nipissing mental...

This document is subject to review and update on a yearly basis. Revised MAR 2016

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Specialized Housing APPLICATION

ADMINISTRATION OFFICE

101 WORTHINGTON STREET EAST SUITE 215

NORTH BAY, ONTARIO P1B 1G5

WEBSITE: www.nmhhss.ca

PHONE: (705) 476-4088

FAX: (705) 495-3585


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NIPISSING MENTAL HEALTH HOUSING AND SUPPORT SERVICES SPECIALIZED HOUSING APPLICATION

Nipissing Mental Health and Housing Support Services has several options of specialized housing. GENERAL ELIGIBILITY REQUIREMENTS FOR ALL HOMES: Nipissing Mental Health and Housing Support Services has several options of specialized housing. GENERAL ELIGIBILITY REQUIREMENTS FOR ALL HOMES:

16 years of age or older, depending on the specific program requirements A serious and persistent mental illness and/ or Acquired Brain Injury (this may not be a

mandatory criteria for the 780 Lakeshore home – under review until June 2016) Must currently reside and be receiving case management services (in the District of

Nipissing) Must be willing to accept daily assistance with any required personal care as well as

activities of daily living Able to communicate with staff and others Being respectful of others in the home to ensure a positive, healthy and safe environment Health and/or safety are potentially at risk if were to live independently Able to take direction from others in an emergency Able to provide financial documentation proving source (s) of income ODSP/OW aware of your change of address

***If you checked “Yes” to all of the above questions then you can continue with the application. _____________________________________________________________________________________ Below are specific descriptions of each of our Specialized Housing Programs. Please check the box(s) of the Homes you would like to apply for:

□ CARRUTHER’S HOME SPECIFIC ELGIBILITY REQUIREMENTS:

Carruthers Home is a barrier free home located within a housing cooperative in the community of North Bay that can accommodate three (3) adults who are living with the effects of an acquired brain injury. Occupant will benefit from a structured, safe and supportive environment as they receive on-site Peer Support 24 hours day, 7 days a week so that they can live and maintain their independence.

□ PERCY PLACE SPECIFIC ELGIBILITY REQUIREMENTS:

Percy Place is designed to accommodate adults who have a serious and persistent mental illness in conjunction with other medical and/or behavioural complexities. Occupant will benefit from a structured, safe and supportive environment as they receive on-site RPN (Registered practical nurse) and PSW (Personal support worker) support 24 hours day, 7 days a week, in addition there will be Peer Support available within the home. A client directed approach allows clients to maintain housing stability and tenure while participating as partners in their care to the level they are capable of.

□ TRANSITIONAL HOUSING SPECIFIC ELIGIBILTY REQUIREMENTS:

The Transitional Home assists occupants in meeting their needs, as indicated in their Service plan. Occupants will work towards goals with the support of their case managers and complimented by Peer Support Workers in the home that will help them learn the skills to live independently. This includes participating in life skills development, as well as broadening knowledge of community resources. In order


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to carry out these objectives, the program has a number of general expectations; Participation in household activities and willingness to follow household rules. Make a commitment to yourself to do as much as you can for yourself as long as you are able, and to live harmoniously in a cooperative living environment.

□780 LAKESHORE SPECIFIC ELIGIBILITY REQUIREMENTS

780 Lakeshore is based on a harm reduction philosophy which reduces negative consequences associated with substance use. Lakeshore will house 4 individuals who have Chronic Long Term Abuse of Alcohol or non-beverage alcohol with a severe dependence as determined by a Severity of Alcohol Dependence Questionnaire (SADQ) or a Physician assessment. In addition to the above criteria, this home is for individuals who are at homeless or at risk of homelessness who may have had frequent involvement with other community agencies such as Police, Withdrawal Management and Emergency Services. Residents will benefit from an open and safe environment that fosters culture of transparency, growth and inclusiveness while recognizing that "growth" can mean different things for different individuals. Some of the services provided are on-site Nursing, PSW (Personal support worker) and other supports to wrap services around the individuals and keep them safe in the community. A client directed approach allows clients to maintain housing stability and tenure while participating as partners in their care to the level they are capable of. It is “VERY IMPORTANT” that you read all the attached information carefully before filling out the application. You can complete the form yourself or someone can help you complete it. If you need more room to answer the questions you can attach additional blank paper to write on. Please complete the form as fully and accurately as possible. Any forms not complete will be returned. Check with your support worker if you need an explanation or more information.

Definitions of Income:

“Income” means all income, benefits and gains, of every kind and from every source.

When complete, please return to:

NIPISSING MENTAL HEALTH HOUSING & SUPPORT SERVICES 101 WORTHINGTON STREET EAST, SUITE 215

NORTH BAY, ONTARIO P1B 1G5

FAX: (705) 495-3585


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A. GENERAL INFORMATION

Name: Date of birth (dd/mm/yyyy):

Support Agency & Worker: Canadian Mental Health Association (CMHA) Nipissing Mental Health Housing & Support Services (NMHHSS) Assertive Community Treatment Team (ACTT) March of Dimes Canada Employment / Rehab Worker CCAC Other Worker’s Name: _________________________________ #___________________________

Address: Health card #: Version:

Gender: Male Female Other Declined

City: Email address:

Province: Phone number:

Postal code: Alternate number:

Marital status: Single Married/Common-law Divorced Partner/Significant other Separated Widowed Declined Unknown

Highest Level of Education: No formal schooling Some Elementary/Jr. High Elementary/Jr. High Some Secondary/High school Secondary/ High school Some College/University College/University

Aboriginal Status/Race: Aboriginal Non-Aboriginal Unknown/Declined

Preferred language: French English Other (please specify):

How do you think residing within this specialized housing will benefit you on your road to recovery?


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B. SUBSTITUTE DECISION MAKER: (Check what applies to your current situation)

I have a Substitute Decision

Maker: Yes No

Name: Contact #:

Power of Attorney-Personal Care:

Yes No

Name: Contact #:

Power of Attorney-Property:

Yes No

Name: Contact #:

Please provide documentation for any of the above which apply to you.

Has there been a capacity assessment: Yes No If Yes, please provide a copy with this application.

C. FAMILY SUPPORT

Next of Kin:

Phone #: Name: Contact #:

Family member:

Name: Contact #:

Phone #: Name: Contact #:

I consent to contact: Y N

D. MENTAL / MEDICAL HEALTH (Please indicate only community clinicians, not hospital personnel unless they

will be following the individual in the community permanently.)

Psychiatrist:

Phone #:

Family physician: Phone #:

Pharmacy:

Phone #:

Psychiatric diagnosis (primary): Secondary psychiatric diagnosis:

Medical diagnosis (primary):

Secondary medical diagnosis:

If Applying for 780 Lakeshore Home Please Provide - Severity of Alcohol Dependence Questionnaire (SADQ) Result Score or For individuals with cognitive impairments the above will be assessed based on physician assessment or review of historical data:

Other:

Medications (If yes, please attach separately):

Yes No Last medication review:__________/__________/__________ dd mm yyyy

Applicants present symptoms, stressors and triggers:


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E. PSYCHIATRIC ADMISSION HISTORY (in the last 5 years):

Has not been hospitalized for psychiatric reasons in the last 5 years

Name and Location of Hospital

Dates (mm/yyyy) Length of Stay Reason for admission

1.

2.

3.

Number of visits to the emergency room, for psychiatric reasons, in the past year?

F. MEDICAL/REHABILITATION FACILITIES ADMISSION HISTORY (in the last 5 years):

Has not been hospitalized for medical reasons

Name and Location of Hospital

Dates (mm/yyyy) Length of Stay Reason for admission

1.

2.

Nature / Type of Injury: Date of Injury:

Motor-vehicle or work-related? Yes No

Insurance / WSIB Yes No

Circumstances surrounding injury:

G. Please list / describe any other disabilities or medical conditions that may affect delivery of your services: (i.e. diabetes, difficulty swallowing, allergies, communicable diseases, special diet, etc)

DNR Status in place Yes No – if yes, must provide documentation.

H.LEGAL STATUS No legal issues (includes absolute discharge and time served – end of custody)

Past Legal Issues?: Yes No Current Legal Issues?: Yes No ORB community access/conditional discharge?

Yes No Yes No Probation: Yes No Parole: Yes No

If yes, please provide details:

I. TRUSTEESHIP

Trustee Designated: Yes No Name of person/agency:

Financial Trustee #:


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Name of person/agency:

Treatment Trustee #:

Signed Consent to Release Personal Info:

Yes No Is the Person aware of the Referral? Yes No

J. INCOME (Gross monthly income before deductions)

You must state all sources of income and provide proof of each.

Ontario Works

Ontario Disability Support Plan

Canadian Pension Plan (Disability)

WSIB/Private insurance

Other

Confirmation of monthly income (ODSP, OW, bank book)

Yes No (office use only)

K. CURRENT ACTIVITIES

Programs/Groups:

Details:

Name of Service Provider:

Programs/Groups:

Details:

Name of Service Provider:

Name of Employer:

L. HOUSING

Are you familiar with congregate housing? Yes No

Have you ever lived in a group setting or with a roommate? Yes No If yes, supervised or unsupervised?

Do you own a vehicle Yes No

Are you willing to live in a non smoking, alcohol and drug-free house? Yes No

Smoker? Yes No

Describe challenges you may have encountered living with a roommate.


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M. ACTIVITIES OF DAILY LIVING (please complete all sections)

Activity Area Do you require assistance?

What level of Support?

1. Medication Yes No Minimal Intensive

2. Time management Yes No Minimal Intensive

3. Finances a. Budgeting b. Banking c. Paying bills

Yes No Yes No Yes No

Minimal Intensive Minimal Intensive Minimal Intensive

4. Food a. Nutrition b. Menu planning c. Grocery shopping d. Meal preparation e. Safety & hygiene f. Clean-up

Yes No Yes No Yes No Yes No Yes No Yes No

Minimal Intensive Minimal Intensive Minimal Intensive Minimal Intensive Minimal Intensive Minimal Intensive

5. House cleaning a. Safety & hygiene b. Product information c. Task oriented



6. Health/hygiene Yes No Minimal Intensive

7. Interpersonal skills Yes No Minimal Intensive

8. Technology a. Telephone/cell operation b. Computer c. Other? ________________



9. Planning a. Social/recreational b. Employment/education

Yes No Yes No

Minimal Intensive Minimal Intensive

10. Transportation a. Transit training

Yes No

Minimal Intensive

N. RISK FACTORS (within the last 3 years)

History of drug and/or alcohol use?

Sexual Risks?

Harm to self or others?

Occupational Therapy assessments completed? Yes No

Behavioural Therapy assessments completed? Yes No

Please attach a copy of all assessments completed.

Neuropsychological assessment completed? Yes No

Date completed: (dd/mm/yyyy) By whom:

Address:

Phone / Contact:

Precautions related to above stated conditions:


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Please identify 3 goals that you would like to work on during your stay.

GOAL AREA

Steps

What has been done to date?

Supports required? (Please identify who the

supports are.)

EXAMPLE:

Connecting with community

Identify interests Review community resources and programs information available in the home Contact other community programs for specific information

Applied to Healthy Living group for September Expressed interest in painting classes

Require transportation – (Case Manager) Physical required – (make appointment) Coordinate with Case Manager

1.

2.

3.

* Please make sure that the following items have been included to ensure the application is complete;

Income verification Proof of SDM/POA- if applicable Capacity assessment- if applicable List of Medication- if applicable Consent form signed DNR Status (if applicable)

This document is subject to review and update on a yearly basis. Revised Nov 2016

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All applicants must sign the declaration and consent in order for their application to be processed.

DECLARATION AND CONSENT

I make the above, the following and all other, whether verbal or written representations to Nipissing Mental Health Housing and Support Services, knowing that they will be relied upon by Nipissing Mental Health Housing and Support Services to assess my qualifications for rental accommodation: 1. The information given on this form is accurate and complete as requested.

I, __________________________________________________________________________

(Print Occupant’s full name) authorize the following agencies to obtain and disclose information for the purpose of determining my need

for service and for Rent Geared to Income housing, and in assisting me with my Individual Service Plan

objectives. This consent will remain in effect for the duration of my time spent living in the home at

_______________________________.

Initial ______ Nipissing Mental Health Housing & Support Services ______ People for Equal Partnership in Mental Health ______ North Bay Regional Health Centre ______ ODSP ______ Ontario Public Guardian and Trustee ______ Medical Pharmacy

Others (i.e. ACTT, CMHA, CHIRS etc):

______ _________________________________________________________ ______ _________________________________________________________ ______ _________________________________________________________

_____________________________________ ____________________________ Occupant Signature Date _____________________________________ ____________________________ Witness Date


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All applicants must sign the declaration and consent in order for their application to be processed.

DECLARATION AND CONSENT

I make the above, the following and all other, whether verbal or written representations to Nipissing Mental Health Housing and Support Services, knowing that they will be relied upon by Nipissing Mental Health Housing and Support Services to assess my qualifications for rental accommodation: 2. The information given on this form is accurate and complete as requested.

I, __________________________________________________________________________

(Print Occupant’s full name) authorize the following agencies to obtain and disclose information for the purpose of determining my need

for service and for Rent Geared to Income housing, and in assisting me with my Individual Service Plan

objectives. This consent will remain in effect for the duration of my time spent living in the home at

_______________________________.

Initial ______ Nipissing Mental Health Housing & Support Services ______ People for Equal Partnership in Mental Health ______ North Bay Regional Health Centre ______ ODSP ______ Ontario Public Guardian and Trustee ______ Medical Pharmacy

Others (i.e. ACTT, CMHA, CHIRS etc):

______ _________________________________________________________ ______ _________________________________________________________ ______ _________________________________________________________

_____________________________________ ____________________________ Occupant Signature Date _____________________________________ ____________________________ Witness Date

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