Addictions Supportive Housing (ASH) Thames Valley 200 ...

Revised August 15, 2012 Addictions Supportive Housing (ASH) Thames Valley 260-200 Queens Avenue London, Ontario N6A 1J3 Fax: 519-673-1022.

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File name: ASH-Referral-Form-2012-08-15.pdf

Revised August 15, 2012

Addictions Supportive Housing (ASH) Thames Valley

260
-
200 Queens Avenue ∙ London, Ontario ∙ N6A 1J3

Fax: 519
-
673
-
1022

The purpose of this form is to provide initial entry for clients into the ASH program. This form
l
lor or the applicant.

ASH has lo
cations in London, Strathroy, Oxford and Elgin County to serve clients throughout
Thames Valley.

To Apply for Addictions Supportive Housing clients must meet the following:

Primary Eligibility Requirements:



Currently experiencing problematic substance

use and history of multiple entries in

the

treatment
continuum



Homelessness

-

CURRENT AND

HISTORICAL TRACK RECORD



including stays in shelter, on
the street, or couch surfing with friends/family



Cannot obtain or maintain housing without support



Not e
xperi
encing a serious
mental illness OR Acquired Brain Injury which

significantly

impairs
judgment
and daily living.

Admission Criteria will include:



Participation

in a comprehensive screening & assessment process in order to develop an
appropriate trea
tment plan



Expression of a strong desire to live independently



Participation

in services that support stabilization
, if required



Must agree to participate in the ASH Program including a treatment plan to change substance use
patterns and practices (c
hange includes harm reduction and abstinence goals as appropriate for
individual) and express a strong desire to make changes in their problematic substance use



Agreement to abide by rules, policies and procedures of program, including refraining from sm
oking
inside the housing units



Client must be willing to commit to their individualized treatment plan as developed in collaboration
with their assigned Intensive Addictions Case Manager for a period up to 364 days



Ability to participate in self
-
manage
ment of unit and basic home maintenance with assistance



Ability to manage personal health care



Legitimate income source



Qualifies for rent supplement



No impending jail terms (otherwise client will be placed on wait list)



No imminent danger to sel
f, staff or other participants

www.adstv.on.ca

for
further information
.

Completed referrals may be faxed to:

(
519) 673
-
1022

ATTN: Addiction S
upportive Housing (ASH)

Revised August 15, 2012

Addiction
s

Supportive Housing
(ASH)
Thames Valley

260
-
200 Queens Avenue ∙ London, Ontario ∙ N6A 1J3

Phone: 519
-
673
-
3242 ∙ Fax: 519
-
673
-
1022

REFERRAL FORM

A. Client Information

Name

(first and last)

Last Name at Birth (if different)

Date of B
irt
h

Gender

Client
has

fixed address?

Which ASH location is client applying to:



Female


Male


Other



Yes


No



Strathroy



Elgin


Oxford


London

Apt. / Unit

City

Postal Code

Personal Phone Number

OK to call?

OK to
leave message?

Call Restrictions



Yes


No



Yes


No

Other Phone
Number

OK to call?

OK to leave message?

Name of Contact Person (if applicable)



Yes


No



Yes


No

Email Address

Preferred Language of Service



English



French



Other:

Client understands that
NO smoking

is allowed inside the
ASH apartments:



Yes


No

Client Initials:

Client understands that

are allowed in the ASH
apartments:


Yes


No

Client Initials:

Client approve direct payment t
o housing if on social
assistance:


Yes


No

Client Initials:

Mental Health

Does the client have a diagnosed mental health issue

(e.g.,
?



Yes



No

If YES:

a)What is
/are the diagnosis/es
?

Wh
en were they made?

b)
Are the symptoms of the mental illness under adequate
control by medication/counse
l
ling?


Yes


No



if YES,
what medication or treatment is the client
receiving?



if NO, describe lingering symptoms:

c)Has client
had thought
s

of suicide

in the last month?



Yes


No

d)Has the client
attempted

suicide in the last 12 months?



Yes


No

If yes,
specify date(s) below:

Identification:

Does the client have
:



a C
anadian birth certificate
?



a
Citizenship Card
?



a L
anded Immigrant Status card?



a SIN card?

NOTE: Copies of these cards, particulary re: citizenship,
will be REQUIRED if the client is accepted to ASH, for
the purposes of processing their Housing application
.

If the client doesn’t have them, t
hey should apply for them
(e.g., at London Intercommunity Health Centre ID clinic)

Income Source:



OW



ODSP



Work



EI



Other _____________



No
ne

Monthly Income amount
: _____________________

Parenting/P
regnancy:

Currently Pregnant?


Yes


No

If YES, what is the due date? _____________________

Is the client currently parenting?


Yes


No

Any current CAS involvement?

____________________________

How many children are they parenting?

__

Ages of children?

_______
How often do they have access to/care of their children
? ___________________________________

Revised August 15, 2012

B. Physical Health and Cognitive Functioning

a)



Yes


No



If YES, describe:

b)
Does the client need regular use of a wheelchair?



Yes


No

….or a walker?



Yes


No

c)
Is the client
physically

able to care for him/herself without assistance

(e.g., feed and bathe themselves, do housekeeping
)
?



Yes


No



If NO, what type of assistance is required?

*

*
client
must

be cap
able of living independently as the ASH program is not staffed 24 hours a day.

d) Does the client have any known cognitive impairments (e.g., memory impairments, learning disabilities, Korsakoff’s
Syndrome/”Wet Brain”, dementia)?



Yes


No



If YES, describe:

e) Does the client have a history of head injury or concussions?


Yes


No



ns, and lingering symptoms…e.g. memory

problems, aggression, etc.).:

C
. Substance Use and Treatment History

Previous Addiction

Treatment

(ADAT tools)
?

Assessment Date (if applicable)



Yes


No



Yes


No

Contacted / Attended
ADSTV before?

Date(s) (month & year) of ADSTV c
ontact (if
known/
applicable)



Yes


No

Please de

Revised August 15, 2012

History of Addictions Treatment (W
ithdrawal Management,
Residential
Treat
ment
, Addiction Counse
l
ling, NA/AA
attendance,

Please provide information below on any previous addictions treatment (please use additional pages if applicable)

Agency
/Service Provider

Name

Start

Date
(dd/mm/yy)

End Date

(dd/mm/yy)

Program

Y/N

1

2

3

4

5

D
. Current Living Arrangements

a)
Please describe client’s current living situation

r it is

b)Can

the

client live there indefinitely or is there a limit
to how long they can stay there (if yes to
the
latter, specify required
move
-
out date)?

c)Does the client currently pay rent where they are living?



Yes


No



If
yes
, how much are they paying?

d)Does the client have any concerns about

th
eir current living environment? Is it inadequate or risky for them in any way,

e) Is the client currently experiencing violence of any kind?



Yes


No



If
yes
, please explain:

Housing/Hom
elessness History

Does the client have a

history

of homelessness, housing instability or inadequate housing
?

(i.e., lived in shelter or on the
street, or had to ‘couch
-
surf’/ stay with friends
,

or live in substanda
rd housing
).



Yes


No

If yes
,

please pro
vide your address history for
the last 5 years

below

(this may include

your own apartment,

shelters or
. Please attach a separate page if more space is needed

Address/Location

Dates Resided

Reason for Moving

___________________________________________________________________________________________________

Revised August 15, 2012

E
. Community Supports

Please provide information below about the communit
y supports
currently

received (e.g., counsel
l

Agency Name

Contact

Length of Involvement

1

2

3

4

5

F
. Legal History

Please provide information regarding current and past legal involvement (criminal and/or

family courts):

Description

Year

Court Decision

1

2

3

4

5

G. Referral

Source

Information

(if not a self referral)

Referring Agency

Contact Person

Telephone Number

Fax Number

Email Address

Signature

Date (dd/mm/yyyy)

H
. Additional Comments

Below, please provide any additional comments you feel are important for processing of this referral:

FOR OFFICE USE ONLY

Date (dd/mm/yyyy)

Name of IACM

Time Spent

Notes

Confidentiality

Information Session

Dat
e of Information Session



Yes


No



Yes


No

Revised August 15, 2012

CONSENT FOR THE RELEASE OF INFORMATION

I _______________________

________________________

Please Print Full Name

Date of Birth (dd/mm/yyyy)

hereby provide my co
nsent to allow

Addictions Supportive Housing Program of
Addiction Services of Thames Valley

AND

Please Print Name of
Referral Agency and/or Individual Contact Name

Contact Phone Number:_______________________________

To share any relevant
inf
ormation

f
or the purpose of
service c
oordin
ation and t
reatment

I understand that this consent is valid for one year from date of signature, and I understand that I may
cancel this consent at any time.

_____________________________

___________________
__

Signature

Date

_____________________________

_____________________

Witness

Date

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