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The Champlain Attendant Services Network
Application for Attendant Services Across the Champlain LHIN.
PLEASE NOTE: THIS APPLICATION IS FOR ATTENDANT SERVICES ONLY.
IT IS NOT INTENDED FOR ACCESSIBLE HOUSING OR FOR HOMEMAKING SERVICES.
IMPORTANT:
Please keep your contact information up to date otherwise we have no way to reach you when the opening becomes available.
General Information Name: __________________________________________ Sex: Female Male
Do you have a valid Ontario Health Card? Yes No
Address: Street ___________________________________________ Apt. _________________
City ____________________________ Prov. ____________ Postal Code ___________
Mailing Address: (if different from above)
Street Apt.
City Prov. Postal Code
Home Phone: ___________________________ Work Phone: ___________________________
E-mail: _______________________________________________________________________
Date of Birth: Day _____________ Month ________________ Year ____________
Language(s) Spoken: English French Other _________________________
Preferred Language of Service: English French
Emergency Contact Information
Name: _________________________________ Relationship: __________________________
Address: Street ___________________________________________ Apt. _________________
City ____________________________ Prov. ____________ Postal Code ___________
Home Phone: ___________________________ Work Phone: ___________________________
E-mail: _______________________________________________________________________
Page 1 of 10 VHA Health & Home Support Version: Dec. 2011
Service Providers for the Champlain LHIN Ottawa Center
Please specify to which Attendant Service Provider(s) you wish to Apply.
FOR THE OTTAWA REGION
ATTENDANT CARE OUTREACH PROGRAM
VHA Health & Home Support (VHA) www.vhaottawa.ca
In Home Attendant Services
SUPPORTINVE HOUSING PROGRAMS
THE IN COMMUNITY (FORMERLY DISABLED PERSONS COMMUNITY RECOURSES) www.theincommunity.ca
145 Clarence
464 Metcalfe Street
1320 Richmond Street
2410 Southvale Crescent
141 Twyford Avenue
88 Forestview Crescent (Group Home)
ONTARIO MARCH OF DIMES (OMOD) www.marchofdimes.ca
3001 Jockvale Road
PARKWAY HOUSE (PH)
2475 Regina Street (Group Home)
PERSONAL CHOICE INDEPENDENT LIVING (PCIL) www.pcilcpva.ca
181 Forestglade Crescent (English)
520 Bronson Avenue (French)
1604 Pullen Avenue (Transitional Group Home)
Attendant Services are available for students attending post-secondary education and living in residence at Carleton University or Algonquin College.
POST SECONDARY
CARLETON-ALGONQUIN ATTENDANT SERVICES www.carleton.ca/pmc/attendant
Carleton University
Algonquin College
Page 2 of 10 VHA Health & Home Support Version: Dec. 2011
Service Providers for the Champlain LHIN East and West of Ottawa
Please specify to which Attendant Service Provider(s) you wish to apply.
FOR THE CORNWALL REGION (EAST OF OTTAWA)
ATTENDANT CARE OUTREACH PROGRAM Groupe Action is a provider for Prescott – Russell & Rockland region.
Address: 250 Main Street East, Suite 210, Hawkesbury, ON., K6A 1A5 Telephone Number: 613-632-7837 or Toll Free: 1-866-363-3210 Fax: 613-632-5648 Contact: [email protected] www.groupaction.ca
The Canadian Red Cross is the provider for Cornwall and for the Stormont – Dundas & Glengarry region. Address: 165 Montreal Rd., Cornwall, ON., K6H 1B2 Telephone Number: 613-932-0231 Ext: 2253 or Toll Free: 1-888-404-0464 Fax: 613-932-8106 Contact: [email protected] www.redcross.ca
SUPPORTIVE HOUSING PROGRAMS
THE CANADIAN RED CROSS
Cornwall Project at 330 Fourth Street East, Cornwall, ON., K6H 2J4 (13 Units)
Cornwall Project at 15 Edward, Cornwall, ON., K6H 4G6 (3 Units)
Rockland Project at 1026 Laurier Street, Rockland, ON., K4K 1V6 (7 Units)
FOR THE RENFREW COUNTY REGION (WEST OF OTTAWA)
ATTENDANT CARE OUTREACH PROGRAM Ontario March of Dimes is the provider for Leeds, Lanark and Renfrew County region.
Address: 6 Glenwood Place, Unit 6, Brockville, ON., K6V 2T3 Telephone Number: 613-342-1935 Ext: 228 or Toll Free: 1-888-252-9008 Fax: 613-342-7636 Contact: [email protected] www.marchofdimes.ca
This referral is done by:
The Applicant
Family member or relative. Please write your name: ______________________________
If this referral is done by a health professional:
Name of agency: _______________________________________________________________
Your Name: ___________________________________ Position: ________________________
Telephone: ___________________________________ Ext: ____________
Page 3 of 10 VHA Health & Home Support Version: Dec. 2011
Information Regarding Disability
Primary physical disability: ____________________________________________________
Onset of disability: Day _________ Month ___________ Year ____________
Is your ability likely to: Improve Deteriorate Remain Stable
Describe any other disability or condition(s) you have that may affect delivery of services. (i.e. diabetes, mental health condition, heart condition, visual impairment, etc…)
Current Living Situation
Please indicate your current living situation.
Retirement Home Long-Term Care Facility
Rehabilitation Hospital Acute Care Hospital
Chronic Care Hospital Convalescent Home
SHU – Supportive Housing Unit (Apartment with on-site 24-hour care available)
Transitional Living
Shared accommodation with support staff available
Apartment or House with attendant services available
Apartment or House with services paid through insurance/WSIB
Apartment or House with services provided by family/friends/out of pocket
Other (Please specify) ____________________________________________________
With reference to above, please indicate your living arrangement
(Choose as many as applicable)
Living Alone Living with dependent child(ren)
Living with parents/step-parents Living with spouse or other adult
Please indicate the number of years you have been living there: _______________________
Page 4 of 10 VHA Health & Home Support Version: Dec. 2011
Current Services Please identify all your current resources/funding of attendant services.
Attendant Care Outreach Program
Support Housing Unit (SHU) or Support Services Living Unit (SSLU)
Direct Funding Program
Workplace Safety & Insurance Board (Previously Workers Compensation)
Insurance settlement* Insurance payments* Settlement pending*
Personal Support Services arranged through CCAC (Community Care Access Center previously call Homecare) Homemaking services arranged through Community Supports
Family or friends. Please describe: ____________________________________________
Transitional Living or Rehabilitation Facility
Chronic Care Hospital or Long-Term Care Facility (Nursing Home or other Health Care Residential Facility) Use of service dog
Other. Please specify: ______________________________________________________
None
*Note: if you have, or expect to receive an insurance settlement or insurance payments, Workplace Safety and Insurance Board (Previously WCB) or other funds intended for attendant/health services,
you are legally required to provide full disclosure.
Please specify which services you currently receive each week?
Service Number of Visits
(per week)
Number of Hours
(per visit)
Homemaking
Physiotherapy
Occupational Therapy
Nursing
CCAC PSW Services
Other Services (Please Specify)
Page 5 of 10 VHA Health & Home Support Version: Dec. 2011
Service Requirements
Please indicate the daily level of service you require.
Less than 2 hours per day 4 to 6 hours per day
2 to 4 hours per day More than 6 hours per day
Please indicate the number of
Hours you need in:
Morning _______ Evening _______
All other times ___________
Do you normally require service between the hours of 11:00 pm and 7:00 am?
None
Some service (Please specify)
Can you communicate verbally? Yes No
If ‘No’, please indicate the methods/devices are used for communication.
Weight: __________________________ Can you bear weight?
Height: ___________________________ Yes No
What type(s) of transfer(s) do you use? (Check all that apply)
Transfer unassisted Two person lift
Transfer using sliding board Floor based lift
Ceiling track lift
Pivot – with minimal assistance/belt/disc
Pivot – with full assistance/belt/disc
Other (Please specify): _____________________________________________________
Date of last transfer assessment performed by a registered Occupational Therapist?
_____________________________________________________________________________
Page 6 of 10 VHA Health & Home Support Version: Dec. 2011
Service Requirements Continued…
Is your present living situation suitable? Yes No
If unsuitable, please indicate why (i.e. architectural barriers, elderly parents having difficulty providing care, unsafe environment, etc…).
Are you prepared to move?
Are you prepared to move immediately? Yes No
If not, please indicate when you believe you will be prepared.
In 1 to 3 months In 3 to 6 months In 6 to 1 year 1 year +
If a supportive housing Unit becomes available with your preferred providers but it isn’t your preferred location, would you be willing to move to that location?
Yes No
Correspondence
From time to time, we have been requested by local community agencies to send correspondence regarding special events, research studies, etc., to the applicants on the Central Waitlist for attendant services. Would you like to be on our distribution list?
Yes If ‘Yes’, in what language(s):
No Both official languages
English only
French only
Additional Information
Is your house smoke free? Yes No
Are there any pets in your household? Yes No
If ‘Yes’, please indicate what kind:
Do you need help with pet care? Yes No
Page 7 of 10 VHA Health & Home Support Version: Dec. 2011
Support Service Assistance
Please complete the charts below by selecting the appropriate option.
Transfers No assistance required
Some assistance required
Full staff assistance required
Chair to chair
In/out of bed
Onto/off toilet/commode
Bowel & Bladder No assistance required
Some assistance required
Full staff assistance required
Bladder routine
Bowel routine
Medication/suppositories
Stoma care
Incontinent briefs
Dressing/Undressing No assistance required
Some assistance required
Full staff assistance required
Lower body
Upper body
Footwear
Outer wear
Buttons/zippers/hooks
Braces/prosthesis
Page 8 of 10 VHA Health & Home Support Version: Dec. 2011
Support service Assistance Continued…
Personal Care/Hygiene No assistance
required Some assistance required
Full staff assistance required
Bath/shower
Bed bath
Hair/make-up/shaving
Peri-care
Sanity napkins/tampons
Taking medication
Respiratory Care
Skin Care No assistance
required Some assistance required
Full staff assistance required
Reposition during the night
Special skin care/treatments
Food & Drink No assistance
required Some assistance required
Full staff assistance required
Meal preparation
Cutting up food
Feeding
Splints/straw/drinks
Tube feeding
Housekeeping No assistance
required Some assistance required
Full staff assistance required
Dusting
Mops/sweep/vacuum
Dishes
Laundry
Garbage
Making/changing bed
Page 9 of 10 VHA Health & Home Support Version: Dec. 2011
Declaration & Content
I ___________________________, declare all statements in this application to be correct and complete.
I hereby give consent that the information provided will be used to assess my suitability for attendant
services. I also give consent to VHA Health & Home Support to collect and share my personal
information with the individuals/organizations listed on page two, page three and those identified
below:
o Community Care Access Centre (CCAC)
o Community Partners (i.e. MS Society , Canadian Paraplegic Association , Staff of
Rehabilitation Center , Other (Please provide name) ________________________ )
o Informal Caregivers. Please provide names:
__________________________________, __________________________________
o Emergency Contacts. Please provide names:
__________________________________, __________________________________
o Other. Please provide names:
__________________________________, __________________________________
The purpose for collecting, using, disclosing or retaining your health information may include:
For provision of direct health care,
Payment for services and treatment,
Administrative planning,
Accreditation and licensing,
Quality improvement activities,
Risk management activities,
Teaching,
Legal use as required by law
I understand that all my personal information is stored securely and confidentially according to the
Ontario Privacy Legislation: Personal Health Information Protection Act, 2004. I understand that my
personal information may be shared via telephone, in writing, or electronically. I have been advised of
the purpose of the collection, use, disclosure and retention of my health information as identified above
and approve of this process and discharge VHA Health & Home Support from all claims, demands,
actions, and causes of action in connection with the collection, disclosure, release and sharing of said
information.
I understand that I may at any time, amend or revoke this release and consent by notifying VHA Health
& Home Support in writing or by registered mail. Changes will be effective seven business days after
receipt.
Signature/Mark of Applicant (PRINT NAME) __________________________________________
Date ____________________
ATTENTION: Please keep a copy of this application for future
reference. FAX to: 613-238-1306
Page 10 of 10 VHA Health & Home Support Version: Dec. 2011