CognitiveDisability

Strategy

AmendmentPackage

Ministry of SocialServices

CDSAmendmentRev.07/14

Important Information for this Package

Inordertoassistyouinprovidingthebest,mostcompleteinformationwhenapplyingtotheCognitiveDisabilityStrategy,andavoidhavingyourapplicationreturned,a“GuidetoCompletingCDSPackages”has been developed. In the guide, you willfind:

-A handy reference to help provide additional information and clarification when filling outtheNewApplication,Renewal,andAmendmentPackages;

-A glossary that defines commonly-usedterms;

-A Frequently Asked Questions (FAQ) section that will help provide a little moreclarificationaroundCDSapplicationsprocesses,etc;

-A collection of helpful forms for invoicing, service provision, accounting, andsamplecontracts;and

-SampleBudgetSheetsandGoalSettingWorksheets.

Application Checklist

Amendment may be requested for the followingreasons:

1.Daily Living Support Assessment has been redone to show a change inlevel.

2.Change in the unmetneed.

3.Change in the plan to respond to a previously identified unmetneed.

RequiredinformationwhenapplyingfortheCognitiveDisabilityStrategy:

ThefullycompletedCognitiveDisabilityStrategyAmendmentPackagewhichincludes:

Consent for Release ofInformationApplicationForm

Integrated PlanningTeamCorrespondenceRationale forAmendment

Goal SettingWorksheet***BudgetProposal***

Submit Amendment packageto:

Consent for Release ofInformation

TheCognitiveDisabilityStrategycommitteeswillbereviewinginformationthatissubmittedtodecideifyou/your child’s support needs could be best met through accessing funding or behaviouralsupportfromtheCognitiveDisabilityStrategy.

Before the Cognitive Disability Strategy committees can review your information, consentfromyou/aparent/legalguardianisrequired.

I/Parent or LegalGuardian,of understandthefollowingdocumentshavebeenenclosedwiththeapplication/renewal/amendmentforCognitiveDisabilityBenefits:

Application/Renewal/Amendmentpackage

NotificationofAssessment(NOA)fromCanadaRevenueAgency

Other:

IconsenttothisinformationbeingreleasedbytheMinistryofSocialServices,CognitiveDisabilityStrategyIntakeCommitteesandCognitiveDisabilityStrategyConsultantsforpurposesof:

a)Determining if I/my child is eligible to receive Cognitive DisabilityBenefits.

b)Determining if I/my child can access the supports from the Cognitive DisabilityConsultant.

Theinformationbeingreleasedisfor (nameofpersontheapplication/renewal/amendmentisfor).

IunderstandthisinformationwillbereleasedtotheCognitiveDisabilityCommitteeswhichconsistofrepresentativesfromthefollowingorganizations:

Ministry ofJusticeMinistry of SocialServicesMinistry ofHealthMinistry ofEducation

CognitiveDisabilityConsultantsandtheirhostagenciesHostAgencies

Community-BasedOrganizationsSaskatchewanAbilitiesCouncilInc.

I understand that members of the Cognitive Disability Committees will review theirspecificorganization information only to determine if there is a role that someone in their organizationhaswiththeidentifiedindividualANDtoassistindeterminingiftheidentifiedindividualmeetsthecriteriafor the Cognitive DisabilityStrategy.

IunderstandthatafilewillbeopenedwiththeMinistryofSocialServices.Thepurposeofthisfilewillbe to allow for payments to be made if Cognitive Disability Benefits areapproved.

IunderstandtheMinistrymayhaveinformationaboutme/mychildrelatedtooneormoreofthefollowing:

  • Information relating to: financial assistance, employment programs, training allowancesandbenefits, employment assistance for persons with disabilities, career and employmentservices,seniors benefits, child care subsidy programs, child care inspections, investigations,licensing,fundingorqualifications,intellectuallychallengedindividualsandapprovedprivate-servicehomeoperators. (Protected under The Freedom of Information and Protection of PrivacyAct).
  • Informationrelatingto:medicalreports,doctor’snotesorlettersandmedicalassessments.

(ProtectedunderTheHealthInformationProtectionAct)

  • Information pertaining to: Child and Family Services involvements. (Protected under TheHealthInformation ProtectionAct)

IfurtherunderstandthattheMinistrywillonlyreleaseasmuchinformationasisrequiredinordertoprocess theapplication.

I understand that I have the right to revoke this consent at any time and that revocation ofthisconsent may be made orally or in writing to Ministry officials. I understand that my revocation ofthisconsent is not retroactive and therefore does not affect uses or disclosures that have alreadybeenmade according to my prior consent. I further understand that the withdrawal of consent mayresultin the inability to determine eligibility and may result in my application beingrejected.

Signature ofapplicantSignature ofparent/guardianDate

Unless a shorter time frame is noted, consent does not extend beyond 12 months. New consentsarerequired after 12months.

For MSS useonly:
Expiry date ofconsent:
Reasonable assurance consent is informed andvoluntary: / Yes / No
Withdrawal ofconsent:
Datereceived:
Details of withdrawal: (Provide date and details as to how consent was withdrawn. Ifwithdrawnin writing, attach withdrawal to thisdocument.)

Saskatchewan Cognitive Disability Strategy ApplicationForm

ApplicantInformation:

Date ofapplication:
Name: / Phone#:
HomeAddress: / City: / PostalCode:
MailingAddress: / City: / PostalCode:
Date of Birth(YYYY/MM/DD): / Health#:
Gender: / Diagnosis (ifknown):

Is theapplicant a permanentCanadianResident?YesNo

Constitutional Status(voluntary):StatusIndianNon-StatusIndianNotApplicableDoesapplicantliveonReserve: Yes Reserve No

(pleasespecify)

Applicant (18 or older) or caregiver currently receiving Social Assistance? (Checkone)Saskatchewan Assistance Plan(SAP) Saskatchewan Assured Income for Disability(SAID)BandAssistance Name ofBand:

Is theapplicantcurrentlyattendingschool?YesNo

SchoolName:Division:

Is theapplicantcurrentlyattending a dayprogram?YesNo

Day ProgramName/Provider:

Please complete ifapplicable:
Istheremorethanoneindividualwithadisabilitylivinginthefamilyhome?
Please see Line 3 of the Reference Section of “Guide to Completing CDSPackages”
Yes / HowMany? / No /

CaregiverInformation:

Name ofparent/caregiver: / Contact#:
Relationship toApplicant:
Parent / FosterParent / Approved HomeOperator
Other (pleasespecify)
Address ofParent/Caregiver: / Same asapplicant / Separate fromapplicant
MailingAddress: / City: / PostalCode:

Primary Community Services PlanningInformation:

Primary Community Services PlanningPerson:
See Line 1 on the Reference Section of “Guide to Completing CDSPackages”
AgencyName: / Phone#:
AgencyAddress: / City: / PostalCode:
Phone#: / EmailAddress:

AdditionalInformation:

Inthespaceprovided,pleaseincludeapplicant’scurrentsituationandhowthisindividual’sdailylivingis impacted by their disability. (See Line 2 of the “Guide to Completing CDSPackages”)

Integrated PlanningTeam

See Line 4 of Reference Section in “Guide to Completing CDSPackages”
Team member name,agencyand contactinformation / Role they play ontheindividual’steam / How did theindividualsparticipate in the creationofthe integratedplan?

Correspondence

PleaseidentifywhoyouwouldlikecorrespondenceregardingCognitiveDisabilityStrategytobesharedwith:

Name: / Address: / Phone:
Agency: / Email:
Name: / Address: / Phone:
Agency: / Email:

Rationale forAmendment

Please provide a detailed explanation of why you are requesting an amendment to the original plan.Besure to provide all reasons that have led to the need for theamendment.

Goal SettingWorksheet

SeeLine6ofReferenceSectionof“GuidetoCompletingCDSPackages”

Individual’s desiredoutcome(goal) / Rationale / Specific steps requiredtomeet desiredoutcome / Personresponsible

BudgetProposal

1.Please identify all funds currently being received on behalf of theapplicant.
Identify funding that hasbeenreceived from othersources
e.g. Community Living ServiceDelivery,Child and Family Services, Level ofCarefunding from Income Assistance,homecare,etc. / What is funding being usedfor?
e.g. respite, transportation ,travel,support contract,etc. / Monthly amountreceived
2.PleaseidentifyfundsbeingrequestedfromCognitiveDisabilityStrategy.
What will CDS funding be used for? Please identify all proposed budget items. Proposed budget items mayincludethings like wages, number of hours of support, mileage, program costs, etc. (Please note this is not an exhaustive list).Ifyou need more space, please attach additionalpages.
Budget item (one perline) / Cost
Total Proposed BudgetRequest / MonthlyTotal
$ / YearlyTotal
$

CDS Amendment Package | Page 9 of9