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Coordinated Access eferral Form - The Access Point

Coordinated Access Referral FormContact our office at 416 640 1934 | Fax: 416 499 9716 | 661 Yonge Street, 4th floor, Toronto, ON, M4Y 1Z9 Page 1 of 23 AAbout this form With this form , you can apply for individual support services (like Intensive Case Management or Assertive Community Treat-ment), Supportive Housing, or both. This form is designed to assist The Access Point in finding housing and/or support services that closely matches the infor-mation you provide and the more accurately you fill out this form , the better this match will be. Missing or inaccurate informa-tion may slow the assessment process.

Coordinated Access eferral Form Contact our office at 416-640-1934 Fax: 416-499-916 661 Yonge Street, 4th floor, Toronto, ON, M4Y 1Z9 Page 1 of 23

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Transcription of Coordinated Access eferral Form - The Access Point

1 Coordinated Access Referral FormContact our office at 416 640 1934 | Fax: 416 499 9716 | 661 Yonge Street, 4th floor, Toronto, ON, M4Y 1Z9 Page 1 of 23 AAbout this form With this form , you can apply for individual support services (like Intensive Case Management or Assertive Community Treat-ment), Supportive Housing, or both. This form is designed to assist The Access Point in finding housing and/or support services that closely matches the infor-mation you provide and the more accurately you fill out this form , the better this match will be. Missing or inaccurate informa-tion may slow the assessment process.

2 Applicants applying for supportive housing must be willing to accept some level of support from a housing provider. Please read the Declaration and Consent section of the application form and note that consent must be provided in order to process an application. The confidentiality of the information you provide will be respected in adherence with the Personal Health Information Protec-tion Act (PHIPA). Services provided by The Access Point partners is Individual Support Services (Check all programs to which you wish to apply) INTENSIVE CASE MANAGEMENTD escriptionOne-on-one support to live in the community and be linked to ap-propriate services by their Case ManagerEligibility Criteria Mental health concerns that are seriously affecting your life 16 years of age or older Live within the City of Toronto when service is re-ceived ASSERTIVE COMMUNITY TREATMENT TEAMS (ACTT)

3 DescriptionMulti-disciplinary teams provide treatment, rehabilitation and sup-port to people with severe mental illness in their recoveryEligibility Criteria Specific Diagnosis with a priority for those experienc-ing psychosis History of hospitalizations - supporting hospital records are recommended The referral source needs to provide a detailed explaination in the Reason for Referral section regarding why the applicant needs ACTT services specifically 16 years of age or older Live within the City of Toronto when service is re-ceivedCoordinated Access Referral FormContact our office at 416 640 1934 | Fax.

4 416 499 9716 | 661 Yonge Street, 4th floor, Toronto, ON, M4Y 1Z9 Page 2 of 23 CSupportive Housing (Check all programs to which you wish to apply) MENTAL HEALTH SUPPORTIVE HOUSING PROGRAMD escriptionSupportive housing for persons with mental health concerns includ-ing addictions. The Access Point facilitates linkages to supportive housing programs with various levels of support and includes shared housing such as group homes, boarding homes and room-ing houses, as well as independent Criteria 16 years of age or older Have mental health or mental health and addictions issues Qualify for a housing subsidy under the criteria set by the Ministry of Health Must be willing to accept some level of support from housing provider PROBLEMATIC SUBSTANCE USE PROGRAMD escriptionSupportive housing for persons with problematic substance use.

5 The Access Point facilitates linkages to low support independent Criteria 16 years of age or older Have a severe and active substance use challenge Be homeless or marginally housed Be a high intensity service user of ER Departments, hospitals, and/or the justice system Qualify for housing subsidy under the criteria set by the Ministry of Health Must be willing to accept some level of support from housing provider MENTAL HEALTH AND JUSTICE PROGRAMD escriptionMental Health and Justice Supportive Housing Program. The Ac-cess Point facilitates linkages to low support independent Criteria 16 years of age or older Have mental health challenges that are seriously affecting your life Be homeless or at immediate risk of homelessness Have current involvement with the Criminal Justice system at time of housing intake Be referred by a priority referral source such as vari-ous professionals working in the justice system Qualify for housing subsidy under the criteria set by the Ministry of Health Must be willing to accept some level of support from housing providerCoordinated

6 Access Referral FormContact our office at 416 640 1934 | Fax: 416 499 9716 | 661 Yonge Street, 4th floor, Toronto, ON, M4Y 1Z9 Page 3 of 23 DIndividual Support Services Agency Preferences Leave this section blank if you wish to be connected with the first available agency If you would prefer NOT to be connected to an agency enter an x beside its name Indicate your first choice of agency by entering a 1 beside its name; Indicate your second choice of agency by entering a 2 beside its name; Indicate your third choice of agency by entering a 3 beside its nameIs this a team to team transfer?

7 YES NO416 Community Support for WomenCTYS - Central Toronto Youth ServicesSound TimesAcross BoundariesHong Fook Mental Health AssociationSt. Joseph s Health CentreAcross Boundaries (Youth)LOFT Community ServicesSt. Michael s HospitalAlternativesMadison Community ServicesSunnybrook HospitalBayview Community Services s Housing & Community Sup-port ServicesThe Scarborough HospitalCMHA (Toronto East)Mount Sinai Hospital - ACTTT oronto East General HospitalCMHA (Toronto West)North York General Hospital - ACTTT oronto North Support ServicesCotaReconnect Mental Health ServicesUniversity Health NetworkCRCTR egeneration Community ServicesWest Neighbourhood House (formerly St.)

8 Christopher House)ESupportive Housing Agency Preferences Leave this section blank if you wish to be connected with the first available agency If you would prefer NOT to be connected to an agency enter an x beside its name Indicate your first choice of agency by entering a 1 beside its name; Indicate your second choice of agency by entering a 2 beside its name; Indicate your third choice of agency by entering a 3 beside its name All Housing programs require applicants to be willing to receive support services offered by the housing Information & SupportGood Shepherd Non-Profit HomesParkdale Activity-Recreation CentreBayview Community Services ServicesPilot Place SocietyCentre for Addiction and Mental HealthHong Fook Mental Health AssociationProgress PlaceChai Tikvah FoundationHouse of CompassionRegeneration Community ServicesCMHA TorontoHouselink Community HomesRouge Valley Health SystemCOPAJean Tweed CentreSt

9 Stephens Community HouseCommunity Outreach ServicesJohn Howard SocietySt. Jude Community HomesCotaLOFT Community ServicesStreet Haven at the CrossroadsEden Community HomesMadison Community ServicesToronto Community Addictions Team - TCATFred Victor CentreMainstay HousingWoodGreen Community ServicesGeorge Herman HouseMargaret s Housing & Community Sup-port ServicesYWCA TorontoCoordinated Access Referral FormContact our office at 416 640 1934 | Fax: 416 499 9716 | 661 Yonge Street, 4th floor, Toronto, ON, M4Y 1Z9 Page 4 of 23 FContact InformationFirst Name:Last Name:Aliases (AKA):Street Address:Nearest Intersection:Apt #:Entry Code:City.

10 Province:Postal Code:Telephone #:Extension:Alternate Phone:Email:Are you currently homeless?YES NOAre you currently at risk of becoming homeless or marginally housed?YES NOIf no fixed address please provide possible locations where person might be found:GAlternate Contact InformationIf you do not have a phone or are otherwise hard to reach, is there someone with whom you are in regular contact that we can call in order to reach you?First Name:Last Name:Phone:Extension:Relationship:Organi zation:Can a message be left at the number provided?YES NOCoordinated Access Referral FormContact our office at 416 640 1934 | Fax: 416 499 9716 | 661 Yonge Street, 4th floor, Toronto, ON, M4Y 1Z9 Page 5 of 23 HGeneral InformationHave you completed an Ontario Common Assessment of Need (OCAN) in the past 6 months?


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