ABI APPLICATION FOR SERVICE

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1 ABI APPLICATION FOR SERVICE INSTRUCTIONS FOR COMPLETING APPLICATION FOR SERVICE To avoid a delay in processing your application, review the following checklist to ensure you have completed the necessary steps. Review criteria to ensure eligibility. An applicant may be declined services if he/she does not meet the eligibility criteria. Ensure that all areas of the application are completed Include all relevant information that supports the application and assists in determining your needs Ensure that you or your Substitute Decision Maker (SDM) has signed the application Ensure a copy of POA for Finances and/or Personal Care and/or guardianship are included (if applicable) Ensure a copy, from your physician, confirming a diagnosis of a brain injury is included The Champlain ABI Intake/System Navigator will gather all relevant collateral information and present this to the Champlain Acquired Brain Injury Coalition s Admissions Committee. Upon receipt of your application and all required documentation, the Champlain Acquired Brain Injury Coalition Admissions Committee will review your request for service. The Committee (who meets monthly) will make recommendations regarding your request after which you will be contacted with the outcome. Please return completed application form using the attached fax cover sheet to: Champlain Community Care Access Centre Attention: Suzanne McKenna Champlain ABI System Navigator 4200 Labelle Street, Suite 100 Ottawa, ON K1J 1J8 Or call to find the Champlain Community Care Access Centre nearest you: Telephone: x 5963 Fax: Toll free telephone: 310-ccac (2222) Toll free fax:

2 Applicants must meet ALL of the following: ELIGIBILITY CRITERIA Services are provided to individuals with an acquired brain injury (damage to the brain occurring after birth which is non-degenerative or progressive) Age 16 to 65 (with special consideration being given to those individuals over 65 years of age) Individuals have the willingness to increase their independence and express interest in participating in a program to accomplish their goals Individuals, if identified with additional issues (addiction, mental health), must be willing to work with other professionals. DEFINITION OF ACQUIRED BRAIN INJURY 1 An acquired brain injury is damage to the brain which occurs after birth and is not related to a: (See appendix I) APPENDIX I Congenital/Developmental Problems (not considered ABI): Congenital disorder Cerebral Palsy Developmental disability Autism (Pervasive Development Disorder) Process which progressively damages the brain Developmental delay Down s syndrome The damage may be caused: (See appendix II) Traumatically (i.e. from an external force such as a collision, fall, assault or sports injury) Through a medical problem or disease process which causes damage to the brain (internal process or pathology) Factors such as the following will be used in the consideration process: Medical stability/complexity Potential to benefit from therapy or resources offered Primary or co-occurring diagnoses which could be a barrier to the rehabilitation process or to the delivery of service. These may include: psychiatric problems, drug/alcohol dependency or behavioural issues. Spina bifida with hydrocephalus Muscular dystrophy Progressive Process/Disease (not considered ABI): Alzheimer disease Pick s disease Dementia Amyotrophic Lateral Sclerosis Multiple Sclerosis Parkinson s disease and similar movement disorders APPENDIX II Non-Traumatic Causes: Anoxia Aneurysm and vascular malformations Brain tumors Encephalitis Meningitis Metabolic encephalopathy Stroke with cognitive disabilities (eligibility for service may depend on clients needs/goals) 1 Source: Toronto Acquired Brain Injury Network

3 Fax/Télécopie To/Destinataire Suzanne McKenna, Champlain ABI System Navigator Organization/Organisme Champlain CCAC/ CASC de Champlain Fax/Télécopie OR Date Subject/Sujet ABI Application for Services From/De No. of page (including cover)/nbre de pages (y compris la page couverture) Comments/ Commentaires Champlain Community Care Access Centre, a proud member of the Champlain ABI Coalition

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5 Champlain ABI Coalition Application for Service Personal Information of Applicant Name: Last Name, First Name Health Card No Version Code Date of Birth: (dd/ mm/ yyyy) Gender: Female Male Language Preference: English French Other: Interpreter Required? Yes No Home Address: Street City Province Postal Code Alternate Current Living Situation: Accommodatio n Type: Alone With other (specify): House Apartment Building Rooming House Group Home Supportive Housing Long-Term Care Home Other: Marital Status: Citizenship: Canadian Permanent Resident Other: Are you a resident of Ontario? Yes, For how long? No Do you have First Nation Band Affiliation? Yes No Status Number: Family Physician: Address: Street City Province Postal Code Fax: Name of person completing application: Relationship to Applicant: Alternate Champlain ABI Application For Services Page 1 of 6

6 Name: Last Name, First Name Health Card No Version Code Contacts Who should be the main contact to discuss this application? Last Name, First Name Relationship: Address: (if different from applicant) Street City Province Postal Code Work Should the main contact be the emergency contact? Yes No If no, please provide this information: Emergency Contact: Last Name, First Name Relationship Address: Street City Province Postal Code Work Injury/ Event Information Date of Injury/ Event: (dd/ mm/ yyyy) Cause of Injury: MVA: On bicycle or pedestrian Assault Fall Sporting Unknown Trauma other (specify): Non-Trauma (specify): Treating Emergency Hospital: Address: Street City Province Postal Code Fax: Is there history of a previous accident? Yes No If yes, please explain: Champlain ABI Application For Services Page 2 of 6

7 Name: Last Name, First Name Health Card No Version Code Treatment History 2 (if applicable) Yes No If yes, please complete the following: Program/ Facility/ Hospital Dates Involved (dd/ mm/ yyyy) Contact Name and Phone Number Are you receiving or have you applied for other brain injury services? Yes No If yes, please provide: Contact name(s) Phone number(s) Have you ever participated in a neuropsychological assessment? Yes No If yes, name of Assessor: Medical Information If you are on any medication, do you self-administer? Yes No Seizures: Yes No If yes, explain: Type Frequency Describe If applicable, are your seizures under control? Yes No Wheelchair: Yes No If yes, Manual OR Motorized Transfers: Independent Stand-by assistance Full assistance 2 Medical, attendant care, rehabilitation and vocational reports are required (if available) such as: Neurosurgery, Neuropsychology, Speech Therapy, Physiotherapy, Occupational Therapy, Social Work, Psychology, Psychiatry, Assessment and Discharge Summaries. Please attach copies of any available reports to this application. Champlain ABI Application For Services Page 3 of 6

8 Name: Last Name, First Name Health Card No Version Code Medical Information, con t Supervision or assistance with mobility: Yes No If yes, does it apply to: Level surfaces Stairs Both Communication Issues: Yes No If yes, please describe: Cognitive Difficulties (memory, concentration): Yes No If yes, please describe: Have you ever experienced behaviour that is challenging, for example mood disorder, anxiety, social isolation or anger management? If yes, please describe: Yes No Other physical conditions (allergies, diabetes, heart conditions, diet restrictions, etc.) If yes, please describe: Yes No Psychiatric Information Do you have a psychiatric diagnosis? Yes If yes, date/ year of diagnosis: No Nature of diagnosis: Psychiatric consult notes: Included Report to follow Not available Substance Abuse/ Legal Pre-injury history of substance abuse: Yes No Not available Current substance abuse? Yes No Not known If yes, substance abuse treatment recommended? Yes No Are you presently undergoing treatment for addictions? Yes No Is there any history of criminal charges/ probation? Yes No If yes, please describe: Champlain ABI Application For Services Page 4 of 6

9 Name: Last Name, First Name Health Card No Version Code Reason you are applying for service? Applicant/ SDM: Referring Agency: Services/ Supports Requested Supportive Independent Living/ Outreach Residential (24 hour) Day Program Referral Source (can include self, family, friends, professionals, etc.) Name: Last Name, First Name Relationship/Agency Address: Street City Province Postal Code Work Contact Person: Yes No Education and Employment Highest level of education attained: Name of last employer: Position: Year completed: How long? Champlain ABI Application For Services Page 5 of 6

10 Name: Last Name, First Name Health Card No Version Code Financial Information (This section must be completed by the applicant or the person responsible for financial matters) Check source of income (check all that apply): Ontario Disability Support Program (ODSP) Old Age Security (OAS) Workplace Safety Insurance Board (W.S.I.B.) Insurance Accident Benefits* Full-Time Employment Other please describe: (see below) Part-time Ontario Works (OW) Canadian Pension Plan (C.P.P.) Long-Term Disability (private) Employment Do you have direct access to your finances? Yes No If no, name of SDM/ POA: Last Name, First Name Work Do you make your own personal care decisions? Yes No If no, name of SDM/ POA: Last Name, First Name Work * Complete the following information ONLY if in receipt of Insurance Accident Benefits: Lawyer s Name (if applicable): Company: Insurance Adjuster s Name (if applicable): Company: Rehabilitation Case Manager s Name (if applicable): Company: I certify that the above mentioned information is correct to the best of my knowledge. Signature: Date: (Applicant/ Substitute Decision Maker) (D/ M/ Y) Champlain ABI Application For Services Page 6 of 6

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