Concurrent Disorders Support Services Application Form
|
|
|
- Tamsin Pope
- 5 years ago
- Views:
Transcription
1 Concurrent Disorders Support Services Application Form Concurrent Disorders Support Services Client Treatment Consent to the Collection, Use and Disclosure of Personal Information To protect your privacy, CDSS follows the Ontario Personal Health Information Protection Act. To provide you with service, CDSS needs your consent (agreement) to collect, use and disclose your personal information for the following purposes: Coordinate your care and services among current, referring and partnering agencies. Determine your eligibility (from your application form, calls and possible meetings). Assess your needs, based on your own information, information from your current or referring agency and information from diagnostic, hospital or agency reports. Develop service and discharge plans. Refer to other agency services in the partnership that meet your request for service. Refer to services outside the partnership that you agree meet your needs. Contact you or leave messages, either directly or through persons/ organizations that you list on your application form. (Please do not include any names/ places you do not wish us to call.) Provide information for program development, research and evaluation. Please note that information used for these purposes will not identify you. The CDSS is a partnership of agencies. The partners are: 1. AAPRICOT 2. Across Boundaries 3. Breakaway Addiction Services 4. Centre for Addiction and Mental Health 5. Community Head Injury Resource Services 6. City of Toronto Women s Residence 7. City Employment Social Services (OW) 8. City of Toronto Streets to Homes 9. Community Head Injury Resource Services 10. COTA Health 11. Covenant House 12. Dixon Hall 13. East Metro Youth Services 14. Elizabeth Fry Toronto 15. Fred Victor (Inc. CRCT) 16. Gerstein Crisis Response Centre 17. Good Shepherd Ministries 18. Inner City Family Health Team 19. Jean Tweed Centre 20. LOFT Community Services 21. Madison Community Services 22. Native Child and Family Services of Toronto 23. Progress Place 24. Reconnect Mental Health Services (Inc COPA) 25. Regent Park Community Health Centre 26. Renascent Drug Rehab Toronto & Alcohol Addiction Treatment Centres 27. Salvation Army Maxwell Meighen Centre 28. Salvation Army Toronto Harbour Light 29. Salvation Army Homestead Addiction Services 30. Scarborough Housing Help Centre 31. Sherbourne Health Centre 32. Sound Times Support Services 33. South East Toronto Family Health Team 34. St. Joseph s Health Centre 35. St. Michael s Hospital 36. St. Stephen s Community House 37. Street Haven at the Crossroads 38. Toronto Community Addiction Team 39. Toronto Withdrawal Management System 40. Turning Point Youth Services 41. UHN - Toronto Western Hospital 42. West Neighbourhood House 43. WoodGreen Community Services & COSS 44. YMCA Youth Substance Abuse Program Concurrent Disorder Support Services may share information with other departments within Fred Victor. I have had an opportunity to discuss this document and ask questions. I consent to these policies during the period in which I am waiting for or receiving service or until I no longer wish service. Client name: Date (D/M/Y): Client signature: Witness name and signature 1
2 Criteria: Please check ( ) all boxes that apply Application to Concurrent Disorder Support Services (CDSS) The CDSS partnership serves clients who are concurrent: Has, or are suspected to have, a substance use disorder Has, or are suspected to have at least one other psychiatric disorder And are experiencing at least three of the following further complexities: Homeless (or precariously housed) Experiencing active psychosis Polysubstance use (3 or more, excluding nicotine) Dual diagnosis OR ABI OR dementia OR apparent cognitive impairment Between ages of years OR 65+ years Limited daily functioning (self-care, meals, money management, housekeeping, mobility, transportation, medication management) Transitioning from a more supportive environment (ex. hospital, residential treatment, jail) or out of child welfare Women who are pregnant or parenting young children Recent suicide attempt OR recent self-harm OR history of trauma OR involved in the criminal justice system Is your client inadequately served by the current support services or support network? Please explain: *Important: The referred client must meet the above criteria, concurrent with three complexities, and be currently not well served by their supportive network. If the client meets the above criteria, please fill out this entire application form, sign the consent form and fax both to 416/ Client Information Client first name: Last name: Current address/ place: Home address: NFA Major intersection near home address: Toronto East T.O. Scarborough Phone: Alt. phone or contact: Date of birth (D/M/Y): Age Aboriginal? Y N Race/Culture English? Y N Need translator? Y N Language(s) Veteran? Y N Ref. source: Name Agency or check ( ) Self Friend Office phone: Cell: Fax: address: Client s OHIP #: 2
3 Demographics: Check ( ) the client s circumstances at the time of referral. Gender Marital Status Income Education Male Single No income Not in school now Female Separated/divorced Employment In school: Specify type of LGBTQI, Two Spirited Domestic partner Family school (Specify) Married Private insurance Widowed Gov t subsidy: Specify Highest completed grade of Unknown education: Other Employment Current Residence Living Arrangement Legal Issues - Past Year No employment Homeless on street Lives alone No legal problems Casual, sporadic Shelter/hostel With partner/spouse Awaiting sentencing Works independently Room & board With children Awaiting trial/bail Assisted in work Supportive housing With parents Conditional discharge Consumer business assisted With other family Court diversion pgm Sheltered workshop Supportive housing With non-relatives Crim. response assess Volunteer (not paid) congregate (group) Other Fitness assessment Other activity (school, Private house/apt. Citizenship Incarcerated retired, homemaker, Social/subsidized Canadian citizen On parole etc.) housing Landed immigrant On probation Correctional facility Refugee status Pre-charge diversion Other: Unknown/ Other Charge: Reason for referral: Can you as referring worker provide case facilitation during the period of CDSS service? Yes No Client request for men, women, youth or senior services check ( ) up to 2 services: Interim case management Counselling: Substance Use/Mental health Trauma-focused counselling group Trauma-focused individual counselling for women Addiction services Housing support/ assistance in applying Primary care Psychiatric assessment Voluntary trustee (Scarborough only) Client s mental and physical health at time of referral: Diagnosis by psychiatrist: Primary Secondary Unknown Last date of diagnosis: Mental health concerns: Developmental disability Acquired brain/head injury Other cognitive impairment Medical issues/ disease: Physical/ disability/ communication issues Can climb stairs? Y N Community Treatment Order? Substitute decision maker? Y N Name Phone Comments: For the following information, use records, client s recall or best guess (if necessary): Emergency room: Times used past 2 mos. or past year Withdrawal Management: Times used past year: 3
4 Seaton House history: Has the client ever stayed in Seaton House, even one day? Y N Safety planning: To provide appropriate service, CDSS needs to know any recent indication of current risk to self or others. There are no risks, the applicant declines to respond or check below: Recent Deterioration or Current Risk Homeless/ unstable housing Current Risk History Please Explain Any Recent Changes Limited daily functioning Psychotic symptoms Severe depression Attempt at suicide (date) Self-harm (burning, cutting, etc.) Violence or aggression Sexually harmful behavior Trauma/ abuse as child or adult Barred from shelter/ services Release from jail or long-term treatment Crisis/destabilization/ deterioration Client s Active Substance Abuse within the Past Year: Current Substances Abused Frequency Length of use? Increase/ Decrease? Please explain increase/ decrease during the past year Is there a history of withdrawal complications (e.g., DT s, severe dehydration, etc.)? Y N If yes, describe: Client s request (if any) for substance use service: ( ) Service Comments No request; not considering change in substance use. Wants assessment to explore change in substance use. Wants a harm reduction approach to substance use. Wants a stabilization or treatment program based on abstinence. Has completed a crisis response, stabilization or treatment program; wants to continue new/ reduced substance use. Wants assistance with relapse. 4
5 Client s professional contacts: Professional Name Agency Tel/ Cell/ Fax Number Continue?* Physician Psychiatrist Current worker* Current worker* *Workers can be support/ CAS/ housing/parole/ case manager, etc. Will they continue during/after CDSS service? All current medications for physical health, mental health and substance use: Please ask the client to bring medications in their original bottles if being referred to residential services. Name of Medication Purpose of Medication Taking ( ) Not Taking ( ) Any known allergies to medication? Informal supports (for example, family, friend, community member, peer support) can be involved in service, if the client wishes. Name Telephone No. Relationship Please fill out the entire application form, sign the consent form and fax both to 416/ Thank you! 5
YMCA of Reading & Berks County Housing Application
YMCA of Reading & Berks County Housing Application Overall Eligibility Criteria To be eligible for these programs (not including SRO), applicants must be: Homeless Drug and alcohol free for at least 5
Transitional Housing Application
Transitional Housing Application Applicant Information Name: Date of birth: SSN: ID Number: Current address: City: State: ZIP Code: Phone: Email: Name of Last Social Worker or Probation Officer:: Original
COPA PROGRAM REFERRAL FORM Person must be: Years -Living with Addictions -Living within the Toronto Central LHIN boundaries
COPA PROGRAM REFERRAL FORM Person must be: -55 + Years -Living with Addictions -Living within the Toronto Central LHIN boundaries CLIENT INFORMATION First Name: Last Name: Referral Date: Form completed
COPA PROGRAM REFERRAL FORM CLIENT INFORMATION REFERRAL SOURCE INFORMATION. Referral Date:
COPA PROGRAM REFERRAL FORM Individuals must be: 55+ years living with Addictions Living within the Toronto Central LHIN boundaries (Priority given to individuals living west of Yonge St. to Kipling Ave.,north
APPLICATION FOR Page 1/8 RESIDENTIAL TREATMENT
APPLICATION FOR Page 1/8 Instructions: The following form is required to begin the application process to Stonehenge. The form should be printed and completed by hand, then faxed or mailed to Stonehenge
Admissions Package. Mino Ayaa Ta Win Healing Centre Residential Treatment. Fort Frances Tribal Area Health Services Behavioural Health Services
Fort Frances Tribal Area Health Services Behavioural Health Services Mino Ayaa Ta Win Healing Centre Residential Treatment Admissions Package Page 1 of 13 Residential Treatment- Basic Identifying Information
Transitional House Application
St. Joseph Lily House Transitional House Application Date: Legal Name: Date of birth: Social Security #: Driver s License/CA ID # Telephone #: Message Phone#: Are you currently Married Divorced Single
DEPARTMENTS OF MENTAL HEALTH SOCIAL SERVICES AND YOUTH BUREAU
MARYELLEN ODELL County Executive MICHAEL J. PIAZZA, Jr. Commissioner 37A298@dfa.state.ny.us JOSEPH A. DeMARZO Deputy Commissioner Joseph.Demarzo@putnamcountyny.gov GRACE M. BALCER Fiscal Manager 37A279@dfa.state.ny.us
Child and Adolescent Residential Services Referral Packet
Patient Name: Date of Birth: Child and Adolescent Residential Services Referral Packet Please do not reply. See attached questions. We require that you directly answer all questions in this referral packet.
Date: Dear Mental Health Professional,
Date: Dear Mental Health Professional, Attached is the Referral Form required to receive PRP services from Mosaic Community Services. The following is required to complete the application process: Completed
PARTICIPATION APPLICATION and AGREEMENT for CULINARY SCHOOL PROGRAM
Page 1 PARTICIPATION APPLICATION and AGREEMENT for CULINARY SCHOOL PROGRAM PERSONAL INFORMATION First Name Middle Initial Last Name Current Street Address City State Zip code ( ) CELL _( )_HOME @ Email
REFERRAL FORM FOR ADMISSION TO HOMEWOOD HEALTH CENTRE
Date of Referral: REFERRAL FORM FOR ADMISSION TO HOMEWOOD HEALTH CENTRE PATIENT INFORMATION Patient Name: Date of Birth (YYYY-MM-DD): E-mail Business/Mobile Phone: Gender: Health Card #: Version Code:
Mental Health Referral Form
Mental Health Referral Form Mailing Address: Niagara Region Mental Health 3550 Schmon Parkway, Second Floor, Unit 2 P.O. Box 1042 Thorold, ON L2V 4T7 905-688-2854 Toll free: 1-888-505-6074 niagararegion.ca/health
3726 E. Hampton St., Tucson, AZ Phone (520) Fax (520)
3726 E. Hampton St., Tucson, AZ 85716 Phone (520) 319-1109 Fax (520)319-7013 Exodus Community Services Inc. exists for the sole purpose of providing men and women in recovery from addiction with safe,
APPLICATION FORM NAME:
APPLICATION FORM NAME: Application Date: Birthdate: SIN#: Requested Date for Residency: Present Address: Phone #: How long at this address? MSP #: Marital Status: Employment Status: Education: Emergency
Dear Applicant, Abode Services Project Independence 1147 A Street Hayward, CA Ph: (510) Fax: (510)
Dear Applicant, The following agencies are members of the Next Steps Collaborative: Abode Services, Bay Area Youth Center, Beyond Emancipation, First Place for Youth, and Fred Finch Youth Center Rising
Psychiatric Residential Treatment Facility Referral
Psychiatric Residential Treatment Facility Referral Psychiatric residential treatment facility (PRTF) referral information Date of referral: Referral contact: Phone number: Referring facility or agency:
London CAReS: CURA Conference October 23 rd, Five year strategy ( )
London CAReS: Five year strategy (2008-2013) CURA Conference October 23 rd, 2013 Improving the health and housing outcomes of street involved and homeless individuals who live with the effects of poverty,
Dear Haven Applicant: Enclosed you will find The Lake County Haven application. You may mail or fax your completed application to:
Dear Haven Applicant: Enclosed you will find The Lake County Haven application. You may mail or fax your completed application to: The Lake County Haven P.O. Box 127 Libertyville, IL 60048 Fax: 847-680-4360
Crossroads for Women Application
Crossroads for Women Application Application Instructions Please check the box next to the program you are applying to: The Crossroads Albuquerque, NM (must have history of homelessness) Hope House Albuquerque,
DESCRIPTION OF FOLLOW-UP SAMPLE AT INTAKE SECTION TWO
SECTION TWO DESCRIPTION OF FOLLOW-UP SAMPLE AT INTAKE 7 2.1 DEMOGRAPHIC CHARACTERISTICS Table 2.1 presents demographic descriptive data at intake for those who were included in the follow-up study. Data
Addictive Disorders Assessment Form
Addictive Disorders Assessment Form Thorpe Recovery Centre Telephone: 780.875.8890 Fax: 780.875.2161 Email: info@thorperecoverycentre.org CLIENT INFORMATION First Name Middle Name Last Name Phone Number
Addiction Services in the Central West LHIN
Addiction Services in the Central West LHIN Helen Danakas Coordinator, Withdrawal Management Hélène (Leela Leela) Tanguay, PhD, RP, ICADC Coordinator, Narcotics Strategy Overview of Presentation Addiction
Recovery Education for Addictions and Complex Trauma
RULES: Thank you for your interest in RE:ACT ( ). Prior to submitting your application, we require you to read the following program policies. In order to be admitted into this program, these policies
COMMON REFERRAL FORM
DISTRICT OF NIPISSING COMMUNITY MENTAL HEALTH AND ADDICTIONS LONG TERM SUPPORT SERVICES COMMON REFERRAL FORM Assertive Community Treatment Teams 1 and 2, North Bay Regional Health Centre ACTT 1 Phone 705-494-3031
The Phoenix ESTLR/STAR Pre-Screening Form
1 The Phoenix ESTLR/STAR Pre-Screening Form INTERVIEWER NAME: *******DATE: yyyy mmm dd Applicant Data Applicant Name Age D.O.B MMM DD YYYY PHN: S.I.N Tel: Length of abstinence as of today? or Clean Date:
REFERRAL SOURCE GUIDELINES. Listed below is a general outline of the referral, interview and intake process at Last Door Recovery Centre.
REFERRAL SOURCE GUIDELINES Listed below is a general outline of the referral, interview and intake process at Last Door Recovery Centre. 1. Contact Last Door Recovery Centre at 1 888 525 9771 to determine
Turning Point Recovery Society Program Information Guide
Turning Point Recovery Society Program Information Guide CONTACT INFORMATION Turning Point Vancouver: Tel 604.875.1710 Fax 604.874.5752 intaketpv@turningpointrecovery.com Turning Point Richmond Men s:
Mental Health Court Referral Checklist
Mental Health Court Referral Checklist Forms to be turned in with your referral Outagamie County Release-Please have the potential referral initial the checked boxes on the first page and sign and date
Intake Form. Date: Referred By: Name: Phone Number: Religious Affiliation: Where are you currently staying? City?
Intake Form Date: Referred By: Name: Phone Number: Email: Religious Affiliation: Where are you currently staying? City?: Birthdate: Age: Place of Birth: Citizenship: Race: Social Security Number: Marital
Transitional, Intergenerational Group Residence Application. Texas ID# Primary Language: Address: City, State, Zip Code: Phone-home ( ) Phone-work ( )
PERSONAL/FAMILY INFORMATION Name Date Date of Birth / / SS # Gender Texas ID# Primary Language: Marital Status: Single Divorced Common Law Living Together Married & living with Spouse not living with Spouse
BIOPSYCHOSOCIAL SCREENING ADULT
BIOPSYCHOSOCIAL SCREENING ADULT CHART NUMBER: DOB: 1. IDENTIFYING INFORMATION Client Name: Availability: Family Member Name: Availability: Family Member Phone Numbers: Telephone (Day): Telephone (Eve):
HASI Orana and Western NSW Application and Referral Form
HASI Orana and Western NSW Application and Referral Form Before starting the referral please ensure you meet the following eligibility criteria for making a referral as below: Psychiatric Diagnosis / functional
TE WHARE ORANGA NGAKAU REFERRAL FORM
TE WHARE ORANGA NGAKAU REFERRAL FORM REFERRER INFORMATION REFERRAL FROM: NAME: POSITION: POST CODE: PHONE NO: FAX NO: CLIENT INFORMATION CLIENTS FULL NAME: DATE OF BIRTH: PHONE NO: POST CODE: ETHNIC GROUP:
LTSR CRITERIA CHECKLIST (PLEASE PRINT LEGIBLY)
LTSR CRITERIA CHECKLIST (PLEASE PRINT LEGIBLY) Consumer s Name: Date: Person Completing Referral: Agency: Phone: Ext: Email: 18 years or older Crossroads LTSR 337 Tippecanoe Road Smock Pa, 15480 Phone:
First Name Middle Name Last Name Name You Prefer Date
Supportive Housing for Homeless Women & Families Application for Residency First Fruit Ministries 2750 Vance Street Wilmington, NC 28412 Phone 910.794.9656 Fax 910.794.9657 First Name Middle Name Last
Home and Community Based Services (HCBS)
To Whom It May Concern: To be considered for membership, the following must be submitted: 1. A Fountain House Membership Application and supplementary substance abuse questionnaire (included at the end
MHCC Research Demonstration Projects on Mental Health and Homelessness: Toronto Proposal
MHCC Research Demonstration Projects on Mental Health and Homelessness: Toronto Proposal Vicky Stergiopoulos, MD, MHSc, FRCPC Medical Director, Inner City Health Associates Research Scientist, Centre for
Albany County Coordinated Entry Assessment version 12, 11/29/16
Referral Completed by: PRE-SCREENING INFORMATION FOR SHELTER REFERRAL 1. First Name Last Name Date/Time: Other names (including nicknames): 2. Has client previously completed an application for assistance
Arlington County Behavioral Health Care Services
Arlington County Behavioral Health Care Services Drewry Center 1725 N. George Mason Drive Arlington, VA 22205 Sequoia Building 2100 Washington Blvd, 4 th Fl. Arlington County 22204 Our Mission The primary
Community Resource List
Community Resource List CATEGORIES Addictions... 2 Basic Needs... 2 Children & Youth... 3 Community Services... 3 Grief & Bereavement... 3 Employment & Education... 3 Financial Assistance... 4 Health...
Program Application for:
Prince of Peace Center P. O. Box 89 502 Darr Ave. Farrell, PA 16121 724-346-5777 www.princeofpeacecenter.org Program Application for: 1 Referred by HOPE FAITH Head of Household Information Gender Male
Continuing Care Programme At Tabor Group, we believe that ongoing support and care is a vital part of long-term recovery from addiction. For many people, the 28-day treatment programme is only the first
RECOVERY PROGRAM INFORMATION AND REFERRAL FORM
* Note: For the Men s Recovery Program, at this time, we are accepting 1) Fayette county court-ordered clients, 2) clients referred by the KY Department of Corrections, 3) clients referred by Fayette Co.
Alberta s Second Stage Shelters:
Alberta s Second Stage Shelters: Transitioning from Domestic Violence to Stability Carolyn Goard, Alberta Council of Women s Shelters Charlene Rowein, Lloydminster Interval Home Society Rural Homelessness
Addiction Severity Index User Information
Addiction Severity Index User Information The ASI is a multidimentional structured interview introduced by Dr. A. Thomas McLellan in 1980. It is widely used in the United States as a tool for assessing
Address: Spouse/Partner Name: Phone: Address:
Adult Wellness Assessment Please take a few minutes to fill out this form. The information will be helpful in better understanding your individual needs and situation. Thank you. Personal Information Name:
Update on Feasibility of 24-Hour Drop-in Services for Women
STAFF REPORT INFORMATION ONLY Update on Feasibility of 24-Hour Drop-in Services for Women Date: January 7, 2014 To: From: Wards: Community Development and Recreation Committee General Manager, Shelter,
Behavioral Health Providers: Facility/Ancillary Application Addendum
Please complete a separate form for each clinical location. Provider identification Legal business name: Doing business as (if applicable): Address: Anthem Blue Cross and Blue Shield Healthcare Solutions
HIV/AIDS Medical Case Management Acuity Assessment Massachusetts Department of Public Health Boston Public Health Commission
Area of Functioning: HIV Care Adherence Dates of last 2 HIV Appointments: dd/mm/yyyy dd/mm/yyyy Has missed 2 or more consecutive HIV medical appointments in the last 6 months Has missed 1 or 2 (non-consecutive)
Nile-Addiction Recovery Treatment Application for Admission/Prior Authorization
1 Nile-Addiction Recovery Treatment Application for Admission/Prior Authorization Nile-ART staff is unable to help you if we are not aware of your circumstances. Therefore we must proceed with the truth
Client assessment and referral
Referrals Baroona Youth Healing Place Njernda Aboriginal Corporation Client assessment and referral In order for this referral to be assessed: all sections must be completed. all information provided must
Please take time to read this document carefully. It forms part of the agreement between you and your counsellor and Insight Counselling.
Informed Consent Please take time to read this document carefully. It forms part of the agreement between you and your counsellor and Insight Counselling. AGREEMENT FOR COUNSELLING SERVICES CONDUCTED BY
The Salvation Army Homestead
The Salvation Army Homestead 975 West 57th Avenue Vancouver BC V6P 1S4 www.vancouverhomestead.ca Telephone: (604) 266 9696 Fax: (604) 266 7401 Email:homesteadintake@yahoo.ca I.L.U. Application Facilities
Community Homelessness Assessment, Local Education and Networking Groups (CHALENG)
June 2016 Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) Community Homelessness Assessment, Local Education and Networking Groups for, commonly referred to as Project
Referral Form. Emmaus
Referral Form All information provided will be treated with respect and will be held in strictest confidence, subject to the Data Protection Act 1998 and the Emmaus Data Protection Policy (available on
RECOVERY APPLICATION The Foundry Ministries
RECOVERY APPLICATION The Foundry Ministries PERSONAL FIRST NAME MIDDLE NAME LAST NAME LAST PHYSICAL STREET ADDRESS CITY STATE ZIP CELL EMAIL ADDRESS DEMOGRAPHICS GENDER ETHNICITY AGE MARITAL STATUS SINGLE
Administration: Assessor Information First Name: Last Name: Survey Date:
Administration: Assessor Information First Name: Last Name: Survey Date: Agency: Email: Survey Time: Survey Location: Opening Script Hello, my name is [interviewer name] and I work for [organization name].
Domestic & Sexual Abuse Directory
Domestic & Sexual Abuse Directory Darlington Crime and Disorder Reduction Partnership C: The One Stop Shop Address: 13 Horsemarket, Darlington Telephone: (01325) 406170 Email: connexions.reception@darlington.gov.uk
Medications. New Patient Registration. Billing and Insurance. Phone Calls. Prescription Refills. Lab Results and Test Results
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
Mental Health Support
Mental Health Support Services in Brown County Helping a Loved One with a Mental Health Condition Stylephotographs l Dreamstime.com ADRC of Brown County 920-448-4300 300 S. Adams Street Green Bay, WI 54301
Family & Children s Services MENTAL HEALTH SERVICES FOR ADULTS
Family & Children s Services MENTAL HEALTH SERVICES FOR ADULTS You don t have to suffer from mental illness. We re here to help you with problems that seem overwhelming and too difficult to handle alone.
Marriage, Family, and Individual Counselling PROGRAMS AND SERVICES
C O U N S E L L I N G Marriage, Family, and Individual Counselling 2018 2019 PROGRAMS AND SERVICES BEAVER LAKE COUNSELLING SERVICES WELCOME TO BEAVER LAKE COUNSELLING SERVICES! This information packet
REGION 1. Coalition for the HOMELESS Report
2008 Report On any given night, approximately 500 people face homelessness in our area. Homeless people can be adults, young people, couples, or families with children. They are living without shelter,
Behavioral Health Psychiatric Residential Treatment Facility Referral Form
Behavioral Health Psychiatric Residential Treatment Facility Referral Form www.amerihealthcaritasla.com Psychiatric residential treatment facility (PRTF) referral information Date of referral: Referral
Fact Sheet October 2014
SPECIALIST HOMELESSNESS SERVICES Going Home Staying Home District This fact sheet provides an overview of the new specialist homelessness services SHS in the FACS District of NSW. Going Home Staying Home
Crystal Arber. M.S.W R.S.W North Vancouver. British Columbia. p
Crystal Arber. M.S.W R.S.W North Vancouver. British Columbia. p. 340 4529 crystalarber@gmail.com www.crystalarber.com Education: Certified EMDR therapist. EMDR International Association ( 2016) University
- PERSON BEING REFERRED - Age: DOB: SSN: Race: Address: City/State/ZIP: County: Telephone:
Referral Information Initial Contact Date: Updated On: Adult: Clinton Warrensburg Cedar Ridge McCambridge Adolescent: Clinton Columbia Rolla Completed By: Update By: - PERSON BEING REFERRED - Date or ASAP:
Physical Issues: Emotional Issues: Legal Issues:
Men s Facility 1119 Ferry Street Lafayette, IN 47901 Phone: (765) 807-0009 Fax: (765) 807-0030 Hope Apartments 920 N 11th St. Lafayette, IN 47904 Phone: (765) 742-3246 Fax: (765) 269-9110 APPLICATION FOR
Heron Ridge Associates, PLC PARTNER RELATIONAL PERSONAL HISTORY INFORMATION. Client s Last Name First Name M.I. Street Address Date of Birth Age
Case #: Readmit? Yes No Heron Ridge Associates, PLC PARTNER RELATIONAL PERSONAL HISTORY INFORMATION PLEASE PRINT CLEARLY Today s Date: Client s Last Name First Name M.I. Street Address Date of Birth Age
Specialized Mental Health Referral Specialized Mental Health, GRT2 Grand River Hospital Freeport Site 3570 King St East, Kitchener, Ontario N2A 2W1
Specialized Mental Health Referral Specialized Mental Health, GRT2 Grand River Hospital Freeport Site 3570 King St East, Kitchener, Ontario N2A 2W1 Prior to faxing - please call the program secretary at
New Hampshire Continua of Care. PATH Street Outreach Program Entry Form for HMIS
Please refer to the 2014 HUD HMIS Data Standards Version 5.1, available on the NH-HMIS website: www.nh-hmis.org for an explanation of the data elements in this form. Date form completed: Outreach worker
North York Human Services and Justice Coordinating Committee (NY-HSJCC)
North York Human Services and Justice Coordinating Committee (NY-HSJCC) Meeting Minutes September 10, 2015 1:00 p.m. 2:30 p.m. Metro North Court Library, 1000 Finch Avenue West Present: Andrew Graham (Co-chair),
CalOMS Admission Form Instructions
Form Instructions REQUIRED FORM: The Admission form is a required document in the client s file. Each participant s initial admission to the facility and any subsequent transfers or changes in service
The Homeless Census & Homeless Point-in-time Survey Summary report Metro Louisville, 2009
The Homeless Census & Homeless Point-in-time Survey Summary report Metro Louisville, 2009 Prepared by the Coalition for the Homeless 1 Each year, the Coalition for the Homeless prepares two annual counts.
The Salvation Army Homestead
The Salvation Army Homestead 975 West 57th Avenue Vancouver BC V6P 1S4 www.vancouverhomestead.ca Telephone: (604) 266-9696 Fax: (604) 266-7401 Email:homesteadintake@yahoo.ca Enclosed is the Salvation Army
Registration Form Women s Health Initiative
YWCA WHI 1500 14 th St. Lubbock, Texas 79401 Phone: (806) 687-8858 Fax: (806) 784-0698 1 Registration Form Women s Health Initiative Date: Name (Last, First, middle, Maiden) Age: Date of Birth SS # Mailing
Easy Does It, Inc. Housing Application
Easy Does It, Inc. Housing Application Thank you for applying to Easy Does It, Inc. ( EDI ) a non-profit charitable organization dedicated to improving the quality of life of individuals and families recovering
Guadalupe County Veterans Treatment Court Participant s Handbook Updated: October 18, 2016
Guadalupe County Veterans Treatment Court Participant s Handbook Updated: October 18, 2016 Presiding Judges: Honorable Robin V. Dwyer County Court-At-Law Honorable Kyle Kutscher County Judge Guadalupe
Sharon Erdman Senior Operations Manager
Refuge Thames Valley Independent Sexual Violence Advisory Service Sharon Erdman Senior Operations Manager Sharon_erdman@refuge.org.uk Who we are Rachel Barr Service Manager Team of six full time Independent
Client's surname First name Middle name Gender. Telephone no. (home) POA/ SDM Agreeable to referral yes no SDM aware of referral yes no ( ) Address
Referral Form Complete and fax to: 905-430-4000 Or Phone: 1-877-767-9642 website:www.ontarioshores.ca *Please note: Incomplete Referrals will result in a delay as they cannot proceed until all information
Having the Courage to Change. Program Application. A ministry of City Gospel Mission. SS# Driver s License # City State ZIP
Having the Courage to Change A ministry of City Gospel Mission Program Application Date: Prison ID#: GENERAL INFORMATION Personal Information Name Aliases Race/Ethnicity Date of Birth SS# Driver s License
PENNSYLVANIA AUTISM NEEDS ASSESSMENT Middle/High School Module
PENNSYLVANIA AUTISM NEEDS ASSESSMENT Middle/High School Module 1367 caregivers of children in middle school and high school diagnosed with autism spectrum disorders completed this needs assessment module.
Eliada Assessment Center Application for Services
Student s Name: Record # Date of Birth: Race: Biological Sex: Male Female Gender Identity: Male Female Transgender/Non-Binary Date Placement Needed: SSN: - - Legal Custodian: Name, Address, Phone, Email
PERSONAL HISTORY. Name: First Middle Last Mailing Address: Phone # ( ) - Can we leave you a detailed message at this number?
Please fax application to: If you have any questions: Katherine s House 253.856.7948 Gretchen Marshall 253.508.2755 Rita s House 253.833.1044 Jo Cherland 253.797.7189 PERSONAL HISTORY Name: First Middle
DATE: June 1, 2016 REPORT NO. PHSSS Public Health, Safety and Social Services. Manager of Homelessness Services
DATE: June 1, 2016 REPORT NO. PHSSS2016-72 TO: FROM: PREPARED BY: Chair and Members Social Services Committee Jo Atanas, General Manager Public Health, Safety and Social Services David Miskiw Manager of
Application Form Transforming lives together
Application Form Transforming lives together Important points Please answer all the questions in an honest and truthful way. Please write as clearly as you can in black ink This is a legal document, so
Referral Form PERSONAL DETAILS. Reason for Referral: Please indicate clearly your reason for referral: CONTACT PERSONS Next of Kin 1: Name:
Referral Form PLEASE USE BLOCK CAPITALS AND FILL IN AS MUCH DETAIL AS POSSIBLE. PERSONAL DETAILS First Name: Date of Birth: / / Referred for: Surname: Maiden Name: Address: Home Tel Number: Mobile Number:
DO PEOPLE WITH MENTAL ILLNESS FEEL WELCOME IN MY PARISH?
A PASTORAL RESPONSE TO MENTAL ILLNESS RESOURCES FOR THE CATHOLIC COMMUNITY WHY IS THIS IMPORTANT TO MY PARISH COMMUNITY? mental illness is a disease A that causes mild to severe disturbances in thought
Bucks County Drug Court Program Application
Docket Number(s) Bucks County Drug Court Program Application Please read each question carefully before answering. Failure to complete all required Drug Court forms and questionnaires accurately will delay
Comprehensive Outreach Education Certificate Program. & Health Modules. Spring 2014
Comprehensive Outreach Education Certificate Program & Health Modules Community Health Education Center Lowell Community Health Center 161 Jackson Street Lowell, MA 01852 Tel: 978-452-0003 Fax: 978-221-6215
CLIENT QUESTIONNAIRE. Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Relationship: Cell Phone:
CLIENT QUESTIONNAIRE Full Legal Name: DOB: / / Preferred Name: Email: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Can we leave voice messages for you at these numbers? Yes Text Messages?
Applicant s Name (PRINT): Applicant s Signature: Date: Anticipated Admission Date: Time: Staff Approval: Date:
FREEDOM SUBSTANCE ABUSE TREATMENT APPLICATION/REQUIREMENTS for ADMISSION PURPOSE: Our primary goal is to facilitate a stable environment that gives individuals an opportunity to break the cycle of homelessness
CHILDREN'S ADVOCACY CENTER of Laredo Webb County Volunteer Application
CHILDREN'S ADVOCACY CENTER of Laredo Webb County Volunteer Application Thank you for your interest in volunteering with the Children s Advocacy Center of Laredo-Webb County. We look forward to working
NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE
New Port Centre NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne ON, L3K 2N7 Phone (905) 378-4647 Ext 32500 Fax: (905) 834-3002 E-mail: NewPortAdmin@niagarahealth.on.ca
Board Education Session Topic: Care for the Homeless: The Ottawa Inner City Health experience
1900 City Park Drive, Suite 204 Ottawa, ON K1J 1A3 Tel 613.747.6784 Fax 613.747.6519 Toll Free 1.866.902.5446 www.champlainlhin.on.ca 1900, promenade City Park, bureau 204 Ottawa, ON K1J 1A3 Téléphone
ADDICTION SEVERITY INDEX SEVERITY RATINGS
INSTRUCTIONS 1. Leave No Blanks - Where appropriate code: X = question not answered N = questions not applicable Use only one character per item. 2. Item numbers circled are to be asked at follow-up. Items
City of Lawrence 2010 Alcohol Tax Funds Request for Proposals Calendar Year 2010 ( January December) Cover Page
City of Lawrence 2010 Alcohol Tax Funds Request for Proposals Calendar Year 2010 ( January December) Cover Page Agency Name: Program Name: Contact Person: DCCCA, Inc First Step at Lake View Lisa Carter,
Child s name: Nickname: Date of Birth: / / Sex: Male Female SSN: Today s date: / / Parent s Name #1: Home phone: ( ) Cell: ( )
Please fill out the entire form, answering the questions as they pertain to your child or teen. Leave blank any that are unclear or that you want additional clarification on. Thank you. General Information:
Giving People a Second Chance
Giving People a Second Chance Opportunities for Discharge Planning and Reentry from Prison and Jail National Alliance to End Homelessness Conference 2015 Women s Forensic Jail Reentry Program Funding provided