COTA Health now uses this one single application form for our: Mental Health Case Management, Hostel Outreach Program, Dual Diagnosis Case Management, Dual Diagnosis & Justice Case Management and Geriatric Mental Health Case Management services. (Note: Access to our Acquired Brain Injury (ABI) Case Management service is coordinated through the Toronto ABI Network. Applications for this service can be obtained by contacting the Toronto ABI Network at (416) 597-3057 or by visiting their website at www.abinetwork.ca)
When completing this application form please answer as many questions as you can. Please PRINT all answers in ink. Please also read the Declaration and Consent section on page 7 and sign the application form. The confidentiality of the information you provide will be respected in adherence with the Personal Health Information Privacy Act (PHIPA).
You can mail, fax, or hand deliver the completed application form to:
Attn: Client Service Centre, 2901 Dufferin Street, Toronto, ON., M6B 3S7
Tel: 416-785-9230 / Fax: 416-785-9358
PART I
COTA Health offers a variety of case management services to adults living within the City of Toronto. The following is a list of the case management services we offer. Please check off the box of the program for which you wish to apply.
Mental Health Case Management
Available to individuals 16 years of age or older. Applicants must have a mental health issue /diagnosis (substance use/abuse alone are not sufficient as a mental health diagnosis) with long standing difficulty functioning in the community. Applicant must have complex support needs and currently no other case management services in place.
Mental Health & Justice Case Management
Available to adults (18 years +) who are living with serious mental illness. In addition, individuals must have active involvement with the justice system, be out of custody and be assessed by COTA Health as being able to be safely supported in the community by this service and they cannot have any other case management service involved. The COTA Health Mental Health & Justice Case Management Program is offered to residents of Toronto.
Hostel Outreach Program (HOP)
Applicants must be male, older than 16; with significant mental health problems and difficulty functioning in the community. They must have either a recent history of being chronically homeless, or of being homeless for more than 6 months.
Dual Diagnosis Case Management
Available to individuals who are 16 years of age or older. Applicants must be identified as having a developmental disability (i.e. IQ <70/1st percentile) and having a mental health issues/diagnosis (substance use/abuse alone not sufficient as a mental health diagnosis). The applicant must have complex support needs and the applicant does not have case management services in place. Applicant may be accepted if they are diagnosed with Asperger’s and/or FASD if there is a co-occurring mental health issues only; such situations will be approved on a case by case basis. There is an assessment period of up to 6 weeks prior to formal program acceptance to establish the need for specialized services.
Dual Diagnosis & Justice Case Management
Available to individuals who are 16 years of age or older. Applicants must fulfill the eligibility criteria as outlined as above in “Dual Diagnosis Case Management” and must also have current involvement with justice system (e.g. court diversion, probation, prevention program, etc). The applicant must be able to be safely supported in community.
Geriatric Mental Health Case Management
Applicants must be 65 years of age or older with a mental health and/or emotional problem, OR, be of any age with a diagnosis of dementia or age related disorder. The role of the case manager may include assessment, supportive counseling, linking, advocacy, skills teaching, crisis intervention, care giver support and education. Once assessed, appropriate referrals are admitted to a waiting list.
Please identify what area of Toronto the applicant lives in:
North York Scarborough Toronto Etobicoke
Date of Referral (MM/DD/YYYY): / /
PART II
A. HOW CAN WE CONTACT YOU?
Applicant:
First Name: Last Name:
Street Address:
Apt. Number: Entry code: Telephone Number: ( ) Extension:
City: Province: Postal code: - No Fixed Address
Former municipality: North York Scarborough Toronto Etobicoke
Major intersection:
If you do not have a phone or are otherwise difficult to reach, is there someone with whom you are in regular contact that we can call in order to reach you?
Name: Telephone Number: ( ) Extension:
Relationship or Organization:
Can a message be left at the phone number provided? Yes No
Do you have a Substitute Decision Maker? Yes No
What is his/her relationship to you?
Do you have a Power of Attorney? Yes No
If yes, who is it?
If yes, for what?
B. REFERRAL SOURCE INFORMATION (Please complete if not a self-referral):
Referrer’s Name: Agency:
Title:
Telephone Number: ( ) Fax Number: ( )
Street Address: Apt. /Suite Number:
City: Province: Postal code: -
E-Mail Address:
Relationship to applicant:
How long have you known the client?
Do you intend to remain involved with the applicant if he/she secures case management services? Yes No
If yes, please describe the level of involvement that you intend to maintain:
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/ CASE MANAGEMENT APPLICATION FORMC. INFORMATION TO HELP US DIRECT YOUR APPLICATION
Date of Birth: / / Gender: Male Female Transgender Transsexual Other
(MM/DD/YYYY)
Do you have an Ontario Health Card? Yes No Don’t Know
If yes, what is the number?
Do you speak English? Yes No Some
What is your first language(s)? English French Other:
What is your preferred language? English French Other:
Are you of Aboriginal origin? Yes No Don’t Want to Say
COTA Health also offers a range of services in addition to case management services that you might be eligible for. If you are interested in any of the services listed below, please check the appropriate box. This form is NOT an application for these services, but will help us match you with the most appropriate service.
Housing Programs Court Support Programs
Who do you presently live with? Please check all boxes that apply:
Self Spouse/partner Spouse/partner & others
Parents Relatives Non-Relatives
Children (Age/Sex)
Are you currently homeless or at risk of becoming homeless? Yes No Somewhat
What type of housing do you presently live in?
Approved Homes & Homes for Special CareCorrectional/Probation Facility
Domiciliary Hostel
General Hospital
Psychiatric Hospital
Other Specialty Hospital
No fixed address
Hostel/Shelter
Long-Term Care Facility/Nursing Home
Municipal Non-Profit Housing / Private House/Apt. - Client Owned /Market
Rent
Private House/Apt. - Other/Subsidized
Retirement Home/Senior’s Residence
Rooming/Boarding House
Supportive Housing – Congregate Living
Supportive Housing – Assisted Living
(RTF 24 hr Home and Group Homes)
Private Non-Profit Housing
Other:
What is your primary source of income?
ODSPEmployment
Pension / Social Assistance (e.g., Ontario Works)
Employment Insurance
Disability Assistance / No Source of Income
Family
Other:
Are you currently involved with the criminal justice system? (Please note, this will not affect your ability to receive service. It is to help us better direct your application) Yes No Don’t Know
If yes, please indicate dates, types of involvement (including charges) and outcome:
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/ CASE MANAGEMENT APPLICATION FORMD/ HEALTH INFORMATION
Is this your first experience with mental illness? Yes No Unknown
How long have you been experiencing mental health difficulties (i.e., length of time)?
Have you been diagnosed with a mental illness? Yes No Unknown
If yes, what diagnosis/diagnoses?
Have you ever gone to a Hospital Emergency Room due to mental health difficulties?
Yes No Unknown
If yes, how many times have you gone to an Emergency Room in the past two years?
Have you been hospitalized due to mental health challenges in the last two years? Yes No Unknown
If yes, please provide an estimate of the total number of days that you have spent in Hospital, due to mental health difficulties, within the past two years (estimated number of days):
Are you in hospital now due to mental health issues? Yes No
Do you have a psychiatrist? Yes No
If yes, please provide his/her contact information:
Name: Telephone Number: ( )
Do you have a physician (e.g., GP, family doctor, walk-in clinic doctor)? Yes No
If yes, please provide his/her contact information:
Name: Telephone Number: ( )
Do you have any other health conditions, problems (including allergies) or disabilities? Yes No Unknown
If yes, please describe:
Do you have a pharmacy that you go to regularly? Yes No
If yes, please provide his/her contact information:
Name: Telephone Number: ( )
Have you been diagnosed with a developmental delay? Yes No Unknown
If yes, when
What is the degree of developmental disability?
Have you been diagnosed with an infectious disease? Yes No Unknown
If yes, please specify:
Have you been diagnosed with Dementia (i.e. Alzheimer’s Disease)? Yes No Unknown
If yes, when:
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/ CASE MANAGEMENT APPLICATION FORME. APPLICANT’S SUPPORT NEEDS:
Applicant is Requesting Support with:
Managing Specific Symptoms of Serious Mental Health Illness
Developing Daily Living Skills
Finances
Legal Issues
Housing Needs
Relationships
Educational Opportunities
Occupational/Employment/Vocational
Substance Abuse/Addictions Issues
Managing/Reducing Risky Behaviour (please check appropriate box below):
Threat to others/attempted suicide
Aggression or violence (verbal, physical, sexual)
Destruction of property (including fire-setting)
Physical risk (e.g. falls)
Wandering/Roaming
Other (please specify)
Applicant’s Comments Regarding Support Needs:
Please briefly describe the reason(s) for your application. In which areas are you looking for support (e.g., recovery goals, self-care, housing/household care, finances, daily activities/education/employment, relationships, social activities, other)?
Referral Source Comments Regarding Applicant’s Support Needs:
Please briefly describe the reason(s) for referral. What is the present difficulty and in which areas could the applicant benefit from support?
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/ CASE MANAGEMENT APPLICATION FORMF. EXISTING SUPPORTS
Are you currently working with any other service providers? Yes No Don’t Know
If yes, please provide the following information on each service provider with whom you are working:
Agency / Name/Contact Person / Service(s) Received / Telephone Number( )
( )
( )
( )
( )
( )
( )
Please describe the informal supports (e.g., family, friends, faith community, cultural groups/community, other community supports) in your life and how satisfied you are with each of these supports.
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/ CASE MANAGEMENT APPLICATION FORMYOUR DECLARATION AND CONSENT
We promise that the confidentiality of the information you have provided will be respected in accordance with all applicable legislation. Please feel free to call us for more information on how your confidentiality will be preserved. By checking the boxes below and signing this application form, you agree to what is set out in the following statements. Please read it carefully before signing.
APPLICANT’S DECLARATION & CONSENT
I have done my best to ensure that the information provided in this application is correct. Yes No
I would prefer both my referrer and myself to be contacted for the initial assessment. Yes No
I understand that in order to determine my eligibility for individual support services and to identify programs that could best meet my needs, the intake staff:
* Will contact me for further information and to discuss and update me regarding my application.
I give my permission for this. Yes No
* May contact and share information with the Referrer (if any) who signs the Referrer’s Statement below.
I give my permission for this. Yes No
* Contact and share information with the service providers listed on pages 2 and 5 of this application form
(e.g., psychiatrist, physician, other service providers), except for
(if any).
I give my permission for this. Yes No
/ /
Applicant’s Signature Print Name Date (MM/DD/YYYY)
I have chosen to provide verbal consent to all the items checked off above. Yes No
If you have chosen not to consent to any of the above statements, please explain:
REFERRER’S STATEMENT
If another person is referring the applicant, that person (the referrer) must complete this section of the application. By signing this application form, the referrer agrees to what is set out in the statement below. Please read it carefully before signing.
Referrer’s statement
To the best of my knowledge, the information contained in this application is correct.
I have discussed this application with the applicant, explained the role of COTA Health and the application process, and whenever possible, have completed this application together with the applicant.
/ /
Referrer’s Signature Print Name Date (MM/DD/YYYY)
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