4
THE SALVATION ARMY
REFERRAL FORM
P.L.U.S.Program/PLUS Club
Transitional Employment Program
150 Railside Road
North York, Ontario
M3A 1A3
APPLICATION FOR: TEP PLUS
APPLICANT: ______
last name first name middle initial
ADDRESS: ______
POSTAL CODE: ______TELEPHONE: ______
TYPE OF HOUSING: ______
DATE OF BIRTH: D____M____Y____ SEX: M F
MARITAL STATUS: ______
INCOME SOURCE: ODSP GWA OTHER ______
HEALTH CARD NUMBER: ______
SOCIAL INSURANCE NUMBER: ______
LANGUAGES SPOKEN: ENGLISH FRENCH OTHER
DIAGNOSES:______
Primary Secondary
MEDICATIONS:
NAME DOSE SIDE EFFECTS
______
______
______
DESCRIBE COMPLIANCE: GOOD FAIR POOR
PHYSICAL HEALTH LIMITATIONS/ALLERGIES: ______
PSYCHIATRIST:
NAME ______
ADDRESS ______
TELEPHONE ______
CONTACT FREQUENCY ______
______DOES NOT HAVE PSYCHIATRIST
FAMILY PHYSICIAN:
NAME ______
ADDRESS ______
TELEPHONE ______
CONTACT FREQUENCY ______
_____ DOES NOT HAVE FAMILY PHYSICIAN
ODSP WORKER
NAME ______WORKER # ______
ADDRESS ______
PHONE ______FAX ______
PUBLIC TRUSTEE
NAME ______
ADDRESS ______
PHONE ______FAX ______
PROFESSIONALS INVOLVED WITHIN PAST 5 YEARS (COTA, CRCT ETC.):
NAME ______SERVICE ______
TELEPHONE ______STILL INVOLVED YES NO
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NAME ______SERVICE ______
TELEPHONE ______STILL INVOLVED YES NO
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HOSPITALIZATIONS:
HOSPITAL DATES REASON
______
______
______
______HAS NEVER BEEN HOSPITALIZED
HIGHEST LEVEL OF EDUCATION ACHIEVED: ______
COMPETETIVE WORK HISTORY: ______
______
RISK MANAGEMENT:
BEHAVIOUR / YES / NO / DATE OF LAST OCCURANCEAggression-physical
Aggression-verbal
Aggression-sexual
Destruction of property or theft
Drug Abuse
Alcohol Abuse
Suicide threats or attempts
Refusal to comply with instructions
*Previous or current legal involvement
PLEASE COMMENT ON ALL YES RESPONSES:
______
______
______
*If legal involvement, please list charges, outcomes, and if person is currently on probation. If currently on probation, please attach conditions of probation to the referral form.
PREVIOUS INVOLVEMENT WITH THE SALVATION ARMY SOCIAL SERVICES YES NO
T.E.P. BOOTH P.L.U.S.(Bathurst) DATES: ______
HAS THE OCAN (ONTARIO COMMON ASSESSMENT OF NEED) BEEN COMPLETED? YES NO
IF YES, WHO IS THE OCAN lead? ______
INTERACTION WITH OTHERS (OUTGOING, AGGRESSIVE, WITHDRAWN ETC.): ______
______
BEHAVIOURAL INDICATORS OF IMPENDING RELAPSE: ______
______
APPLICANT RECOGNIZES THESE: Y N SEEKS MEDICAL HELP : Y N
EMERGENCY CONTACT:
NAME ______
ADDRESS ______
TELEPHONE ______
RELATIONSHIP TO APPLICANT ______
REFERRING AGENT:
NAME ______POSITION ______
AGENCY ______
TELEPHONE ______
LENGTH OF RELATIONSHIP WITH CLIENT: ______
WHAT SERVICES WILL YOU CONTINUE TO PROVIDE TO THE APPLICANT?
______
HOW LONG WILL YOU STAY INVOLVED? ______
NOTE: All applicants must have a diagnosed psychiatric illness which is preventing them from working competitively at this time. This diagnosis must be specified on the medical report that is attached. All individuals have the right to appeal if their application is not accepted. If accepted into the program, the applicant will be required to sign a service agreement.
______
Signature of referring worker Date