Client Referral

Referral Date

[{viewVars.validations.referralDate}]

In order to ensure compliance with PHIPA and/or your own agency's policy regarding the release of confidential information; please check below that the client has been advised regarding the uses and limits of sharing information

[{viewVars.validations.advised}]

Referring Agency

[{viewVars.validations.agency}]

If other please enter here

[{viewVars.validations.otherAgency}]

Referrers First Name

[{viewVars.validations.referrerFirst}]

Referrers Last Name

[{viewVars.validations.referrerLast}]

Referrers Email

[{viewVars.validations.referrerEmail}]

Referrers Phone Number

[{viewVars.validations.referrerPhone}]

Relationship to Referree

[{viewVars.validations.refRelationship}]

Is the applicant aware of this referral

[{viewVars.validations.awareRef}]

Reason for Referral

[{viewVars.validations.refReason}]

First Name

[{viewVars.validations.firstName}]

Last Name

[{viewVars.validations.lastName}]

First Name Alias (AKA)

[{viewVars.validations.firstNameAlias}]

Last Name Alias (AKA)

[{viewVars.validations.lastNameAlias}]

Date of Birth

[{viewVars.validations.dob}]

Gender

[{viewVars.validations.gender}]

Phone Number

[{viewVars.validations.phone}]

Email

[{viewVars.validations.email}]

Marital Status

[{viewVars.validations.marital}]

What Race do you identify as

[{viewVars.validations.race}]

Clients Current Address

[{viewVars.validations.currentAddress}]

Name - Alternate Contact

[{viewVars.validations.alterContactName}]

Phone Number - Alternate Contact

[{viewVars.validations.alterContactPhone}]

Email - Alternate Contact

[{viewVars.validations.alterContactEmail}]

Relationship - Alternate Contact

[{viewVars.validations.alterContactRel}]

Can a message be left at the number provided?

[{viewVars.validations.messageLeft}]

Source of Income

[{pr}]

If other please enter here

[{viewVars.validations.otherIncomeSource}]

Are you currently homeless?

[{viewVars.validations.homeless}]

Are you at risk of becoming homeless?

[{viewVars.validations.homelessRisk}]

If Yes Explain

[{viewVars.validations.homelessReason}]

Have you been released from a provincially funded institution or service system (prison or hospital?)

[{viewVars.validations.proInstitution}]

What is your current living situation?

[{pr}]

Please provide any additional information you feel we need to know about your housing situation:

[{viewVars.validations.addlInfo}]

Do you have the following ID's ?

[{pr}]

Do you have a Health care provider?

[{viewVars.validations.careProvider}]

Health Care Provider

[{viewVars.validations.careProviderInfo}]

Do you have any physical health issues/allergies

[{viewVars.validations.healthIssues}]

Please answer the following related to your physical health

[{pr}]

If other please enter here

[{viewVars.validations.otherPhysicalHealth}]

Do you have addictions issues?

[{viewVars.validations.addictions}]

How long have you been clean/sober?

[{viewVars.validations.soberTime}]

What steps did you take to achieve sobriety?

[{viewVars.validations.sobrietySteps}]

What is your sobriety/clean date

[{viewVars.validations.cleanDate}]

Do you need a wheelchair accessible unit

[{viewVars.validations.accessibleUnit}]

Are you a victim of domestic abuse

[{viewVars.validations.abuseVictim}]

Do you need support services

[{viewVars.validations.supportService}]

Do you have a developmental disability?

[{viewVars.validations.devDisab}]

Do you have a mental health diagnosis?

[{viewVars.validations.mentalDx}]

Please answer the following related to mental health and substance use disorder

Do you have current or past mental health experiences

[{viewVars.validations.mentalHx}]

Have you ever experienced psychosis

[{viewVars.validations.psychosisHx}]

Do you or have you had an eating disorder

[{viewVars.validations.eatDisorderHx}]

Have you been formally diagnosed with a mental illness?

[{viewVars.validations.mentalDxFormal}]

Have you been hospitalized due to a mental health issues

[{viewVars.validations.mentalHospHx}]

Are you designated as alternative level of care (ALC)

[{viewVars.validations.alcStatus}]

Are you currently on a community treatment order?

[{viewVars.validations.treatmentOrder}]

Do you have a concurrent disorder (substance use and Mental illness)?

[{viewVars.validations.concurrentDis}]

Do you have dual diagnosis (developmental disability and mental health)

[{viewVars.validations.dualDiagnosis}]

Do you have a neurological disability or disorder? (head/brain injury, epilepsy, parkinsons)

[{viewVars.validations.neuroDisab}]

Do you have an intellectual disability?

[{viewVars.validations.intelDisab}]

If other please explain

[{viewVars.validations.otherIntelDisab}]

Please explain allergies

[{viewVars.validations.allergyExplain}]

Please list all medications, including any MAT (Methadonem,Suboxone,Subsolv, Sublicade, Vivitrol etc) you are currently prescribed and the dosage in milligrams.

[{viewVars.validations.medication}]

If you are on MAT medications where will you be receiving these medications?

[{viewVars.validations.medicationMAT}]

Are you prescribed any "Other" Controlled Substances for example (Benzodiazepines, Amphetamines, etc)

[{viewVars.validations.otherSubstanceRx}]

if above is yes - please list

[{viewVars.validations.listOtherSubstanceRx}]

If you struggle with any of the items listed, please indicate how long it has been since the last incident

Items	Time
[{v}]

Have you served in the military?

[{viewVars.validations.military}]

Have you been in touch with VAC?

[{viewVars.validations.vac}]

Are you currently or in the past been involved with the criminal justice system

[{viewVars.validations.involvedCriminal}]

Do you have a criminal record?

[{viewVars.validations.criminalRecord}]

If yes, please explain here:

[{viewVars.validations.criminalRecordReason}]

Please upload a copy of criminal record

[{viewVars.validations.criminalRecordFile}]

View Recent H&P Delete file

Please complete the following if you have current legal involvement

[{pr}]

Would you need assistance from the fire department to leave the building in case of fire or other emergency?

[{viewVars.validations.fireAssistNeed}]

Name

[{viewVars.validations.emergContactName}]

Relationship

[{viewVars.validations.emergContactRelationship}]

Phone Number

[{viewVars.validations.emergContactPhone}]

Email

[{viewVars.validations.emergContactEmail}]

Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA) Completing this form authorizes the release of my personal information to Ryandale Shelter for the Homeless (Ryandale Transitional Housing)

I understand the purpose for disclosing this personal information to Ryandale. I understand I can chose to not complete this consent form.

[{viewVars.validations.consent}]

Electronic Signature

[{viewVars.validations.signature}]

[{viewVars.title}]

Referral Agency Information

Applicant Contact Info

Applicant Info

Applicant Medical Info

Applicant History

Applicant Current Status

Emergency Contact Info

Consent to Disclose Personal Info