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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

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Page 1: The Champlain Attendant Services Network - PCIL/CPVA · The Champlain Attendant Services Network Application for Attendant Services Across the Champlain LHIN. ... Rehabilitation Hospital

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

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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

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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: ____________

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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: _______________________

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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

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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?

_____________________________________________________________________________

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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

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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

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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

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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

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