High Intensity Supports

High Intensity Supports

High Intensity Supports

Referral Form

Referral Criteria

Those being referred to Permanent Supportive Housing or an Assertive Community Treatment Team (High Intensity Supports) must have a history of homelessness: either one year continuous or at least 4 episodes of homelessness in the last 3 years. Those without a history of homelessness will not be considered. Homelessness includes periods on incarceration, hospitalizations, couch-surfing and shelter use.

Required Documentation

Please include the following documentation:

 Consent to Release Information.

 Updated Service Prioritization Decision Assistance Tool (SPDAT) (for submissions from Housing First Programs) or VI SPDAT

 ACLS (for submissions from Alberta Health Services and other programs where available).

Once Completed

Please send all completed referral forms to:

or

Fax to 780.496.2634, attention: High Intensity Supports

Date Application Completed: ______

Date Received by Homeward Trust: ______

  1. CLIENT INFORMATION

Name: ______D.O.B (dd/mm/yyyy): ______
Gender: ______PHN: ______
Address: ______
Current living situation (i.e. sleeping rough, market rental, shelter, etc.) ______
Ethnicity:
  • First Nations/Non-Status
/
  • First Nations/Status
/
  • Metis

  • Inuit
/
  • Caucasian
/
  • Other (Specify:

  1. PARTICIPANT SUPPORT TEAM INFORMATION; Please include all that are applicable.

Name / Phone Number / Email Address
Housing First Program Staff:
Referral Agency/Unit:
Mental Health Supports:
Psychiatrist:
Guardian:
Next of Kin/Family Support:
Trustee/FM HUB Contact:
Persons with Developmental Disabilities Support:
Emergency Contact:
Parole/Probation information:
  1. HOUSING HISTORY

Is the applicant currently housed, or have they previously been housed with Housing First supports? YES/NO
If yes, please complete the following.
Housing First Team: ______
Dates in Program: ______
Number of Rehousings: ______
Circumstances for Eviction(s): ______
______
______
What interventions/supports were put into place, and what were the outcomes of these interventions (attach
separate document if necessary)?
Intervention: ______
Outcome: ______
______
______
Outline all other attempts at independent living (attach separate document if necessary):
______
Outcome: ______
______
______
______
______
  1. SOURCES OF INCOME – ensure to outline financial support contacts in question 2

Formal Income Sources:
C.P.P ______
Income Supports ______
AISH ______
Other ______
Informal Income ______
Total Monthly Income: ______
  1. LEGAL INVOLVEMENT

List any involvement with the legal system and associated risk factors.
  1. MENTAL HEALTH (Please include any medical assessments)

Does the individual have a diagnosed mental illness? YES/NO
Diagnosis:
Axis I:
Axis II:
Axis III:
Axis IV:
Please provide specific symptoms that are impacting the individuals housing:
Does the individual have a suspected (but not diagnosed) mental illness? YES/NO
Please specify symptoms that are impacting the individual’s housing:
7. FETAL ALCOHOL SPECTRUM DISORDER
Has the individual been diagnosed with an FASD? YES/NO
If yes, please include evidence of diagnosis (assessments, hospital records, etc.).
Is the individual suspected to have an FASD but does not have a formal diagnosis? YES/NO
8. SUBSTANCE USE
What are the individuals’ substances and pattern of use?
Please specify symptoms that are impacting the individual’s housing:
9. PHYSICAL HEALTH
Is it anticipated that the applicant’s physical health conditions will require specific interventions/attention in a High Intensity Supports Setting? YES/NO
If yes, elaborate further:
10. SAFETY CONCERNS
Are there any risks that may have the potential to cause harm to people, property, or community well-being (select all that apply, and provide context, including action plans to mitigate concerns)
Aggression towards staff:
Self Injury/self harming behaviors:
Arson:
Sexual Aggression:
Aggression towards others:
Suicidal thoughts/behaviors:
Unsafe smoking:
Gang involvement (include risk from others):
Financial Exploitation:
Theft:
Damage to Property:
Other:
11. INDEPENDENT LIVING SKILLS/STRENGTHS
Please indicate which of the below independent living skills the applicant already possesses to support success in housing (check all that apply):
☐ Adding Structure to their day / ☐ Transportation Skills / ☐ Shopping
☐ Nutrition, Diet, Cooking / ☐ Physical Health & Fitness / ☐ Avoiding Crisis
☐ Obtaining Employment / ☐ Maintaining Employment / ☐ Managing Finances
☐ Developing Positive Relationships / ☐ Looking After Their Home / ☐ Managing Substance Use
☐ Self-Care / ☐ Literacy / ☐ Leisure
☐ Anger Management / ☐ Education/Training / ☐ Getting to Appointments
12. PREVIOUS HOUSING REFERRALS
Please list previous referrals to housing, the referral outcome, and reason not accepted (where applicable).
Program: / Referral Outcome and Reason:
13. COMMUNITY CONNECTIONS
  1. List all current supports that will continue if accepted into a High Intensity Supports program. Include formal and natural supports (Disability services, cultural/spiritual, social, etc).
  1. List all pending and unsuccessful referrals to community support programs including reasons referrals were unsuccessful (i.e. E4C’s Financial Hub, Spady Clinical Access Team, Persons with Developmental Disabilities, etc.).

14. IS THE APPLICANT AWARE OF AND IN SUPPORT OF THIS REFERRAL?
YES/NO
14. WOULD THE APPLICANT CONSIDER SHARED ACCOMODATION WITH A ROOMMATE? YES/NO

Housing First Team Lead/Manager Signature ______

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