1. health and fitness

Addictions Supportive Housing (ASH) Thames Valley
260-200 Queens Avenue ∙ London, Ontario ∙ N6A 1J3
Fax: 519-850-7330
The purpose of this form is to provide initial entry for applicants into the ASH program. This
form may be completed by a service agency, current counsellor or the applicant.
ASH has locations in London, Strathroy, Woodstock and St. Thomas to serve applicants
throughout Thames Valley.
To apply for Addictions Supportive Housing applicants must meet the following:
Primary Eligibility Requirements:
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Currently experiencing problematic substance use or require relapse prevention and history of
multiple entries in the treatment continuum (residential treatment, community treatment, AA/NA,
etc.)
Current and historical track record of homelessness – including stays in shelter, on the street, or
couch surfing with friends/family
Unable obtain or maintain housing without support
Not experiencing a serious mental illness or Acquired Brain Injury which significantly impairs
judgment and daily living.
Admission Criteria includes:
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Participation in a comprehensive screening & assessment process in order to develop an
appropriate treatment plan
Expression of a strong desire to live independently
Participation in services that support stabilization, if required
Must express a strong desire to make changes in their problematic substance use
Agreement to abide by rules, policies and procedures of program, including refraining from
smoking inside the housing units
Required to meet with their Intensive Addiction Case Manager and attend at least one group
weekly
Ability to participate in self-management of unit and basic home maintenance with assistance
Ability to manage personal health care
Legitimate income source
Qualifies for rent supplement
No impending jail terms (otherwise applicant will be placed on wait list)
No imminent danger to self, staff or other participants
Before completing this referral we encourage you to visit our website at www.adstv.on.ca for
further information.
Completed referrals may be faxed to
(519) 850-7330
ATTN: Addiction Supportive Housing (ASH)
Revised April, 2015 MN/Temporary Approval PJH May 2015
Addictions Supportive Housing (ASH) Thames Valley
260-200 Queens Avenue ∙ London, Ontario ∙ N6A 1J3
Phone: 519-673-3242 ext 270 ∙ Fax: 519-850-7330
REFERRAL FORM
1. Applicant Information
Name (first and last)
Gender
Last Name at Birth (if different)
Applicant has fixed
address?
 Female  Male  Other
 Yes
Street Address
Which ASH location is applicant applying to:
(choose one only)
 Strathroy  Elgin  Oxford  London
 No
Apt./Unit
Phone Number
OK to call?
Alternate Phone Number
OK to call?
City
Postal Code
OK to leave message?
 Yes  No
 Yes
 Yes
Email Address
Call Restrictions
 No
OK to leave message?
 Yes  No
Date of Birth
 No
Name of Contact Person
(if applicable)
Preferred Language of Service
 English  French  Other:
Applicant understands that no smoking is
allowed inside the ASH apartments:
 Yes  No
Does the applicant have a pet?
 Yes  No
Applicant Initials:
Applicant understands that no pets are to be
acquired during the ASH program:
 Yes  No
Income Source:
 OW  ODSP  Work  EI
 Other _____________  None
Monthly Income: $__________________
Applicant Initials:
Applicant approves direct payment to housing if on social
assistance:
 Yes  No
Applicant Initials:
Name of OW/ODSP Case Worker: ___________________
Identification:
Does the applicant have:
 a Canadian birth certificate?
 a Landed Immigrant Status card?
 a Citizenship Card ?
 a SIN card?
NOTE: Copies of these cards, particularly re: citizenship, will be REQUIRED if the applicant is accepted to ASH,
for the purposes of processing their Housing application. If the applicant doesn’t have identification, they should
apply for them (e.g., at London Intercommunity Health Centre ID clinic)
2. Dependents
Is the applicant currently pregnant?  Yes  No
If Yes, when is the due date? _______________________
Is the applicant currently parenting?  Yes  No
If yes, how many children are they parenting? _______ Ages of the children:_________________
How often do they have access to/care for their children? __________________________
Is there any current CAS involvement?  Yes  No
Revised April, 2015 MN/Temporary Approval PJH May 2015
3. Health and Cognitive Functioning
Physical Health:
1. Does the applicant have any physical health conditions or challenges? (e.g., hearing impairment,
diabetes, mobility impairments, etc?)
 Yes  No
•
If yes, describe: (use additional sheets if necessary)
 Yes  No
If yes, describe: (use additional sheets if necessary)
2. Does the applicant have any allergies?
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3. Does the applicant need regular use of a wheelchair?  Yes  No
Or a walker?  Yes  No
4. Is the applicant physically able to care for him/herself without assistance (e.g., feed and bathe
themselves, do housekeeping)?  Yes  No
• If no, what type of assistance is required? * applicant must be capable of living independently as the ASH
program is not staffed 24 hours a day.
5. Does the applicant have any known cognitive impairments (e.g., memory impairments, learning
disabilities, Korsakoff’s Syndrome/“Wet Brain,” dementia)?  Yes  No
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6.
If yes, describe:
Does the applicant have a history of head injury or concussions?  Yes  No
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If yes, provide details (dates of injuries, # of head injuries/concussions, and lingering symptoms…e.g. memory
problems, aggression, etc.).:
Mental Health:
1. Does the applicant have a diagnosed mental health issue (e.g., anxiety, depression, PTSD,
schizophrenia etc.)?  Yes  No
If yes:
• What is/are the diagnosis/es? When were they made?
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Are the symptoms of the mental illness under adequate control by counseling and/or medication?
 Yes  No
• If yes, what medication or treatment is the applicant receiving?
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If no, please describe the symptoms:
2. Has the applicant had thoughts of suicide in the last month?  Yes  No
3. Has the applicant attempted suicide in the last 12 months?  Yes  No
• If yes, specify date(s) of attempt(s):
Revised April, 2015 MN/Temporary Approval PJH May 2015
4. Substance Use and Treatment History
Contacted/Attended
ADSTV before?
Date(s) (month & year) of ADSTV contact (if known/applicable)
 Yes  No
Please describe history of substance use (i.e., age of onset of various substances used, and course/history of use)
History of Addictions Treatment
Please provide information below on any previous addictions treatment
(Withdrawal Management, Residential Treatment, Community Treatment, Addiction Counselling, NA/AA, etc.)
Agency/Service Provider Name
Start Date (dd/mm/yy)
End Date (dd/mm/yy)
Program
Completed
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5. Housing/Homeless History
Does the applicant have a history of homelessness, housing instability or inadequate housing? (i.e., lived in
shelter or on the street, or had to ‘couch-surf’/ stay with friends, or live in substandard housing).  Yes  No
• If yes, please provide your address history for the last 5 years below (this may include your own apartment,
shelters or staying with a friend, etc). Please attach a separate page if more space is needed
Address/Location
Dates Resided
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Revised April, 2015 MN/Temporary Approval PJH May 2015
Reason for Moving
6. Current Living Arrangements
1. What is the applicant’s current living situation? (address and whether it is their own place, with family,
etc):
2. Can the applicant live there indefinitely or is there a limit to how long they can stay there?  Yes  No
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If yes, specify required move-out date:
3. Does the applicant currently pay rent where they are living?  Yes  No
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If yes, how much are they paying?
4. Does the applicant have any concerns about their current living environment? Is it inadequate or risky
for them in any way, including regarding risk of relapse, etc?
5. Is the applicant currently experiencing violence of any kind?  Yes  No
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If yes, please explain:
7. Community Supports
Please provide information about the community supports currently received (e.g., counsellor, AA/NA
sponsor, etc)
Agency Name
Contact
Length of Involvement
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8. Legal History
Please provide information regarding current and past legal involvement (criminal and/or family courts)
Description
Year
Court Decision
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Is the applicant currently on Probation/Parole?  Yes
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 No
If yes, who is their probation/parole officer? _________________________________
*note: if on probation/parole, the attached client consent form must be completed to allow ADSTV to contact the
Ministry of Community Safety and Correctional Services to discuss eligibility
Revised April, 2015 MN/Temporary Approval PJH May 2015
9. Referral Source Information (if not a self referral)
Referring Agency
Contact Person
Telephone Number
Fax Number
Email Address
Signature
Date (dd/mm/yyyy)
Note: before faxing the finished application, the attached Client Consent Form must be completed. All
service providers that are involved with the applicant may be contacted. If an applicant is currently on
OW/ODSP or Probation/Parole, a signed consent is required to discuss eligibility with these service
providers.
10. Additional Comments
Below, please provide any additional comments you feel are important for processing of this referral:
FOR OFFICE USE ONLY
Date (dd/mm/yyyy)
Intensive Addiction Case Manager
Notes
Information Session Scheduled
 Yes
Date of Information Session
 No
Revised April, 2015 MN/Temporary Approval PJH May 2015
Time:
Addictions Supportive Housing Program
Client Consent Form
I, _________________________, ________________________ of ______________________________
Last Name
First name
Address
I have placed my initials beside the names of those service providers who I agree may share my
personal information.
____ all Addiction Supportive Housing Program collaborative partners, or
____ only those specified:
____ Regional HIV/AIDS Connections
____ Middlesex London Health Unit
____ Addiction Services of Thames Valley
____ Ministry of Community Safety and
____ At^lohsa Native Family Healing
Correctional Services
____ Canadian Mental Health Association
(Probation/Parole)
Middlesex, Oxford and/or Elgin
____ Mission Services
____ Centre for Addiction and Mental
____ Ontario Works
Health
____ Ontario Disability Support Program
____ Child Welfare Agency
____ Oxford County Public Health Unit
____ Elgin/St. Thomas Public Health Unit
____ Oxford County Housing
____ Elgin St. Thomas Housing Corporation
____ Salvation Army
____ London Abused Women’s Centre
____ Strathroy Caradoc Police Services
____ London CAReS
____ St. Joseph’s Health Centre
____ London Health Sciences Centre
____ Unity Project and Region
____ London Intercommunity Health Centre
____ Women’s Community House
____ London Police Services
____ Women’s Rural Resource Centre
____ London and Middlesex Housing
____ Other
Corporation
Previous Treatment or Addictions Services (please specify):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Other (please specify):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
For the purpose of: Service Coordination and Treatment
This Consent is valid for the following period: One year from date of signature
I understand that I may revoke this consent in writing at any time.
_______________________________________
Signature of Client
__________________________
Date
_______________________________________
Witness
__________________________
Date
Revised April, 2015 MN/Approved PJH May 2015
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