APPLICATION FOR SUPPORTIVE HOUSING

PEEL CHESHIRE HOMES INC. 361 Queen Street South, Mississauga ON L5M 1M3

APPLICATION FOR SUPPORTIVE HOUSING
Applicant

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Office Use: Date Received

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Initials:
PLEASE NOTE:

THIS INFORMATION IS BEING COLLECTED FOR THE PURPOSE OF FACILITATING YOUR APPLICATION FOR ATTENDANT SERVICES AND SHALL ONLY BE RELEASED IN ACCORDANCE WITH THE TERMS SET OUT IN THIS APPLICATION OR AS PEEL CHESHIRE HOMES MAY BE REQUIRED BY LAW.
PLEASE CHECK (√) AND MAKE SURE YOU MEET THE FOLLOWING ELIGIBILITY REQUIREMENTS BEFORE YOU COMPLETE THE APPLICATION.
- You have a valid Ontario Health Card.
- You are at least 16 years of age.
- You have a PERMANENT PHYSICAL DISABILITY and require PHYSICAL ASSISTANCE with activities of daily living such as bathing, dressing, transferring and toileting.
- You must be able to direct your own services.
- You must be able to have your health needs met by the existing community health network on a visitation basis.
IF YOU DO NOT MEET THE ABOVE ELIGIBILITY REQUIREMENTS, YOUR APPLICATION FOR ATTENDANT SERVICES WILL NOT BE ACCEPTED AND WILL BE RETURNED.

2. ALTERNATE CONTACT INFORMATION
Name

First NameLast Name
Relationship
ADDRESS: Name of organization (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Fax

Area CodePhone Number
Pager

Area CodePhone Number
E-mail
DID SOMEONE ASSIST YOU WITH FILLING OUT THIS APPLICATION? If YES, please provide contact information below.)

YesNo
Name

First NameLast Name
Relationship
ADDRESS: Name of organization (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Fax Number

Area CodePhone Number
Pager

Area CodePhone Number
E-mail

3. DISABILITY INFORMATION
Select ONE main permanent physical disability that requires you to use attendant services ( Do NOT choose more than ONE. List other additional disabilities at the bottom of this page):
DISABILITY INFORMATION
Specify One Only:
Attendant services may include assisting you with medication. Please describe which medications you take at present, including name, dosage and reason: (One line per drug)
Please describe how this disability affects your day-today functioning:
Please explain
OTHER DISABILITY: Please list/describe any other disabilities or medical conditions that may affect delivery of your services (i.e., visual impairment/ blindness, hard of hearing/deafness, epilepsy, HIV/AIDS, etc.):

4. MEDICAL INFORMATION
Can your medical needs be met within the community; i.e., visiting nurses, etc.?

YesNo
If NO, please explain:
Medical History
Attendant services may include assisting you with medication. Please describe which medications you take at present, including name, dosage and reason: (One line per drug)
FAMILY PHYSICIAN INFORMATION
Name

PrefixFirst NameLast Name
ADDRESS: Name of institution (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Office Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Pager

Area CodePhone Number
Fax

Area CodePhone Number
E-mail

Please check

	Yes	No
Do you wear classes/contacts?
Do you use a hearing aid?

Please Check:

	All the time	Sometimes	No
Do you need assistance with these communication aids?
Do you need assistance to use the telephone?

7. ATTENDANT SERVICES QUESTIONNAIRE
The following questions are necessary for planning purpose and because of certain cost sharing agreements with the Federal Government. They in no way affect your priority for services.
Can you direct your attendant services? This means that you are able to take responsibility for yourself and tell the attendant what you need and how to perform the task.

Yes, I am able to direct attendants verbally or otherwise. Explain below:No. If the answer to this question is NO, you are not eligible for attendant services. Please contact us for a more appropriate referral.
Please explain above (if Yes):
Community Activity
Are you currently working?

YesNo, if No please explain below
If No, please explain

Please Check:

	Yes	No
Are you a volunteer?
Are you going to school?

8. ATTENDANT SERVICES CHECKLIST
Please check (√) which services you require and specify types of assistance and hours of services per week:
SERVICES
SPECIFY TYPES OF ASSISTANCE for each service that You receive:
Specify the HRS./WEEK that You require for each service checked:
ESCORT/SUPPORT ACTIVITIES
Please Indicate Other
Do you require assistance with housekeeping?
HOUSEKEEPING ACTIVITIES

SIGNATURE
DECLARATION, CONSENT TO DISCLOSURE OF APPLICANT INFORMATION AND RELEASE FROM LIABILITY
I, the undersigned or the authorized representative, certify thatthis application is complete and correct, to the best of my knowledge.
Signature: Applicant or authorized representative’s name
City & Province
Date

MonthDayYear
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Medical History