ABI APPLICATION FOR SERVICE

(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: 613-745-5525 x 5963 Fax: 613-745-0649

(2)

ELIGIBILITY CRITERIA Applicants must meet ALL of the following:

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

Spina bifida with hydrocephalus The damage may be caused: (See appendix II) Muscular dystrophy

● Traumatically (i.e. from an external force such as a collision, fall, assault or sports

injury) Progressive Process/Disease (not considered ABI):

● Through a medical problem or disease process which causes damage to the brain (internal process or pathology)

Alzheimer disease Pick’s disease Dementia

Amyotrophic Lateral Sclerosis Factors such as the following will be used in the

consideration process: Multiple Sclerosis Parkinson’s disease and similar movement disorders

● Medical stability/complexity

● Potential to benefit from therapy or

resources offered APPENDIX II

● 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.

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)

(3)

Champlain Community Care Access Centre, a proud member of the Champlain ABI Coalition

Fax/Télécopie

To/Destinataire

_{Suzanne McKenna, Champlain ABI System Navigator}

Organization/Organisme

_{Champlain CCAC/ CASC de Champlain}

Fax/Télécopie

_{613-745-0649 OR 1-888-990-8150}

Date

Subject/Sujet

_{ABI Application for Services}

From/De

No. of page (including cover)/Nbre de pages (y compris la page couverture)

(4)

(5)

Champlain ABI Application For Services Page 1 of 6

2.86 (14/04)

Champlain ABI Coalition

Application for Service

Personal Information of Applicant

Name:

Last Name, First Name Health Card No Version Code

Date of Birth: _Gender: Female

(dd/ mm/ yyyy) _Male

Language

Preference: English French Other:

Interpreter Required? Yes No

Home

Address: Street City Province Postal Code

Home Phone: Alternate Phone:

Email: Current Living Situation:

Alone

With other (specify): Accommodatio

n Type:

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

Phone: Fax:

Name of person completing application: Relationship to Applicant:

Home Phone: Alternate Phone:

(6)

2.86 (14/04)

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)

Home Phone: Work Phone:

Email:

Should the main contact be the emergency contact? Yes No If no, please provide this information:

Emergency Contact:

Last Name, First Name Relationship

Address:

Home Phone: Work Phone:

Email:

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:

Phone: Fax:

Is there history of a previous accident? Yes No If yes, please explain:

(7)

2.86 (14/04)

Name: _{Last Name, First Name} _{Health Card No} _{Version Code} Treatment History2_{(if applicable)} _Yes _No

If yes, please complete the following:

Program/ Facility/ Hospital _{(dd/ mm/ yyyy)}Dates Involved 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: Phone:

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.

(8)

2.86 (14/04)

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? Yes _No If yes, please describe:

Other physical conditions (allergies, diabetes, heart conditions, diet

restrictions, etc.) Yes _No

If yes, please describe:

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

(9)

2.86 (14/04)

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

Education and Employment

Highest level of

education attained: Year completed:

Name of last employer:

Position: How long?

Referral Source (can include self, family, friends, professionals, etc.)

Name:

Last Name, First Name Relationship/Agency

Address:

Home Phone: Work Phone: Email:

Contact Person:

Yes No

(10)

2.86 (14/04)

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) Ontario Works (OW)

Old Age Security (OAS) Canadian Pension Plan (C.P.P.)

Workplace Safety Insurance Board (W.S.I.B.) Long-Term Disability (private)

Insurance Accident Benefits* (see below) _{Part-time Employment}

Full-Time Employment

Other – please describe:

Do you have direct access to your finances? Yes No

If no, name of

SDM/ POA: Last Name, First Name

Home Phone: Work Phone:

Email:

Do you make your own personal care decisions? Yes No

If no, name of

SDM/ POA: Last Name, First Name

Home Phone: Work Phone:

Email:

* Complete the following information ONLY if in receipt of Insurance Accident Benefits: Lawyer’s Name (if applicable):

Company: Phone:

Insurance Adjuster’s Name (if applicable):

Company: Phone:

Rehabilitation Case Manager’s Name (if applicable):

Company: Phone:

I certify that the above mentioned information is correct to the best of my knowledge.

Signature: Date: