Application for CAT Services

The George Spady Society Clinical Access Team is founded upon the principles of harm reduction and wellness recovery. Spady CAT helps Housing First participants with complex challenges such as physical health, mental health and substance use, to better integrate into community services. The program does not duplicate existing intensive case management or clinical services that are already in place nor does it provide crisis supports. Participants retain their Housing First Intensive Case Management (ICM) Teams, where applicable.

Consent is a legal requirement. FOIPPA and HIA Waivers allows for information sharing between Spady CAT, the referring agency, and other formal and natural community supports. The Team maintains a client-led focus throughout services and involvement is always voluntary.

Please print:

Date:
Applicant Name: / ETO #:
Birthdate (mm/dd/yy):
Phone Number(s):
Address: / SPDAT:
Worker Name:
Referring Agency: / Worker Phone:
Worker Email:
Income (circle one): FIS, AISH, Employment, Other.
Cultural Status (circle one): Non-Status Aboriginal/or Metis, Status Aboriginal, Not Aboriginal. / Family Involvement in Care:
(circle one): Yes, No, or Discuss further at Intake interview

Client Synopsis:

Describe areas of highest acuity relative to the most recent SPDAT score. (A SPDAT under 40 requires detail on items at a score of 3 or 4.)

SPDAT Score:

Reason for Application:

How are the areas of acuity impacting the client’s ability to remain housed, or creating other negative consequences?

Previous Interventions and referrals:

What referrals or services have been tried? What worked? What did not work?

Client Goals:

What are the goals that the participant has self-identified in working with Spady CAT?

Documentation Included:

FSW Risk Screen (required)ICM Service Plan Other

Consent to Release(required)ICM Safety Plan______

SPDAT (required)Mental Health Assessment______

Referring Worker Signature ______

Team Lead Signature ______

Participant Signature: ______

Please submit application and attached documentation in either Word of pdf format to:

George Spady Society Clinical Access Team

#213, 10509 – 81 Avenue

Edmonton, Alberta T6E 1X7

Phone: (780) 756-3917 / Fax: (780) 756-3921

FSW RISK SCREEN

The information provided will promote safety for the participants, their friends and family, and their workers.

QUESTIONS to be answered by Support Worker:
If you do not know the answer to a specific question, use this tool to ask the participant and/or their other support workers or Team Lead. Answers cannot be marked as “unknown.” / RISK
YES orNO / SEVERITY
1=MILD 5=MODERATE 10=SEVERE / CONTEXT
How Long ago?
How Often?
Any Patterns?
Does the participant ever act out violently (e.g. physical altercations which may include domestic violence, use of weapons, etc.)?
Does the participant ever threaten violence or other aggressive behavior (e.g. posturing, challenging, kicking inanimate objects, etc.)?
Has the participant ever committed a violent or sexual offence? (Please provide context: e.g. within the family, outside of the family, in self-defense, etc.)
Has the participant ever had a restraining, no contact, or emergency protection order filed against them? (Please provide context.)
Is the participant involved with persons who are abusive or dangerous to participant?
Is the participant involved with persons who are abusive or dangerous to visitors?
Is the participant in an abusive relationship with an intimate partner or family member?
Does the participant have a restraining order, no contact order, or emergency protection order filed against someone else?
Does the participant have suicidal ideation?
Has the participant attempted suicide?
Does the participant have homicidal ideation?
Does the participant self-harm (e.g. cut, themselves, burn themselves, pull their hair, hit themselves, etc.)?
Is a Safety Plan in place? / If YES; please attach.
Does the participant have a consistent negative response to men?
Does the participant have a consistent negative response to women?
Does the participant have a consistent negative response to younger workers (approximately under the age of 30)?
Does the participant have a consistent negative response to older workers (approximately over the age of 55)?
Does the participant have a consistent negative response to a specific race, ethnicity or cultural orientation?
Does the participant have a consistent negative response to persons with disabilities?
Does the participant have a consistent negative response to persons of a specific sexual orientations?
Does the participant have a consistent negative response to people meeting with them alone?
Does the participant have a consistent negative response to people when meeting with two or more workers at a time?
Does the participant have a consistent negative response to any specific surroundings (e.g. doctor’s office, inner city, bus, etc.)?
Does the participant have medical issues that impact their impulse control or cognitive functioning and reasoning? (e.g. FASD; brain injury; organic brain disorders, etc.)?
Does the participant have a consistent negative response to specific personal behavioral discussions (e.g. blaming others, being late, not showering, etc.)?
Does the participant have an unsafe living space (e.g. clutter,needles, bed bugs, spills, weapons, etc.)?
Does the participant have a private living space (e.g. others cannot overhear conversation, lives alone, does not have constant company, etc.)?
Does the participant have any aggressive animals residing with him/her?
OTHER COMMENTS:
Signatures required. Participant: ______FSW: ______
Date:

Version March 2018