RESOURCE MATCHING AND REFERRAL

From: #:

To: #:


CNAP Application

! / Consent (Express consent is best practice. Please document if you captured consent for the information to be disclosed to facilitate this referral.) / top
Express / Implied
! / Consent obtained from / top
Client / SDM
! / Consent obtained from (specify) / top
First Name
Last Name
Relationship
! / Consent captured by: / top
Given and Surname

! / Consent captured on / top
Date {Mon DD, YYYY}

! / Urgent Situation? (Client requires contact from an agency within 1 Business day) / top
Yes / No
! / Urgent Situation Comments (Client requires contact from an agency within 1 Business day). / top
{Specify} Urgent Situation Comments (Client requires contact from an agency within 1 Business day). / top
! / Additional Information / Additional Information top
{Detail}
! / Special Calling Instructions / Special Calling Instructions top
{Specify}
! / Living Situation / Living Situation top
Lives Alone / Homeless / Smoker
Lives Without Support / Temporary Address / Pets
! / Referral Source / Referral Source top
CCAC / Another CSS Agency / Internal (this CSS Agency)
Hospital ED / Hospital Inpatient Unit / Family Doctor
Hub Phone Referral / Caregiver / Other
! / FARM Status (frail, at-risk, and marginalized status) FARM Status (frail, at-risk, and marginalized status) / top
Inform the Client that you need some additional information to better understand his/her situation. Use these questions to guide your conversation with the Client, rather than reading them word-for-word. Indicate FARM status on the last line in the table below, based on your assessment of the Client's current status (note: no need to add or score responses below).
! / Services requested or receiving are possible FARM indicators? Services requested or receiving are possible FARM indicators? / top
Yes / No / Unknown
! / Comment Comment / top
{Additional FARM Indicator Potential Information}
! / Lives alone without support? / Lives alone without support? top
Yes / No / Unknown
! / Comment / Comment top
{Additional Living Situation and Support Information}
! / Physical or cognitive impairments? / Physical or cognitive impairments? top
Yes / No / Unknown
! / Comment / Comment top
{Additional Physical or Cognitive Impairment Information}
! / Admitted to hospital (emergency or otherwise) within 3 months? / Admitted to hospital (emergency or otherwise) within 3 months? top
Yes / No / Unknown
! / Comment / Comment top
{Additional Hospital Admissions Information}
! / Fallen within the last 3 months? / Fallen within the last 3 months? top
Yes / No / Unknown
! / Comment Comment / top
{Additional Fall Information}
! / Access to a family physician? / Access to a family physician? top
Yes / No / Unknown
! / Comment / Comment top
{Additional Family Physician Information}
! / Visited family physician in last 6 months? / Visited family physician in last 6 months? top
Yes / No / Unknown
! / Comment / Comment top
{Additional Physician Visit Information}
! / Recently had trouble accessing a health service? / Recently had trouble accessing a health service? top
Yes / No / Unknown
! / Comment / Comment top
{Additional Health Service Access Information}
! / Homeless or temporary address? / Homeless or temporary address? top
Yes / No / Unknown
! / Comment Comment / top
{Additional Residence Information}
! / Possible caregiver issues (abuse, stress)? / Possible caregiver issues (abuse, stress)? top
Yes / No / Unknown
! / Comment / Comment top
{Additional Caregiver Issue Information}
! / Based on your professional assessment, using the answers above as a guide, is this client's status FARM? / Based on your professional assessment, using the answers above as a guide, is this client's status FARM? top
Yes / No
! / Services - Currently Receiving / Services - Currently Receiving top
Adult day program / Caregiver support / Case management
CCAC / Crisis support & assistance / Foot care
Friendly visiting / Group dining / Health promotion
Home help or homemaking / Home maintenance & repair / Hospice care
Informal supports / Lifeline / Meals on Wheels
Mental health support / Personal care or support / Respite
Security check / Social & recreational / Social work
Shopping assistance / Shopping list pickup / Shopping trips
Supportive housing / Transportation / Other (explain)
! / Current Program Agency NameCurrent adult day program / top
! / Services - Requested / Services - Requested top
Adult day program / Caregiver support / Case management
CCAC / Crisis support & assistance / Foot care
Friendly visiting / Group dining / Health promotion
Home help or homemaking / Home maintenance & repair / Hospice care
Informal supports / Lifeline / Meals on Wheels
Mental health support / Personal care or support / Respite
Security check / Social & recreational / Social work
Shopping assistance / Shopping list pickup / Shopping trips
Supportive housing / Transportation / Other (explain)
! / Requested Service - Comments /
! / Has the client been diagnosed with Alzheimer's disease or dementia? Has the client been diagnosed with Alzheimer's disease or dementia? / top
Yes / No
! / Comments / Comment top
{Specify}
! / Does the client have Alzheimer's disease and/or dementia and are they in need of overnight stay services? / Does the client have Alzheimer's disease and/or dementia and are they in need of overnight stay services? top
Yes / No
! / Comments / top
{Specify}
! / Does the client's family or caregiver need education/counselling for diseases of dementia? / Does the client's family or caregiver need education/counselling for diseases of dementia? top
Yes / No
! / Comments / Comment top / Comment / top
{Specify} / top
! / Does the client experience chronic pain? / Does the client experience chronic pain? top
Yes / No
! / Comments / Comment top / Comments / top
{Specify} / top
! / Does the client suffer from irregular sleep patterns? / Does the client suffer from irregular sleep patterns? top
Yes / No
! / Comments / Comment top / Comment / top
{Specify} / top
! / Does the client exhibit behavioural issues? / Does the client exhibit behavioural issues? top
Yes / No
! / Comments / Comment top / Comment / top
{Specify}
! / CNAP Application: Additional Comments / CNAP Application: Additional Comments top
{Specify}
Last modified by ______.

RM&R CNAP Application - 1