APPLICATION FOR SERVICE page 1

Application Administration Centre

2080 Trinity Church Road, Binbrook, ON L0R 1C0
(905) 692-4465, Ext: 245. www.ableliving.org

Please provide as much information as possible. You will be contacted by telephone

regarding your application. We look forward to answering your questions.

PART 1: PERSONAL INFORMATION

Last Name: First Name:

Middle Name: Sex: Male Female Marital Status:

Address: Apt. #:

City: Province: Postal Code:

Home #: Cell: Work:

Email Address:

Ontario Health Card #: Date of Birth:

Languages Spoken:

Current Living Arrangement: House Apartment Other:

Currently Living With: Spouse Minor Children Adult Children Other

My Substitute Decision Maker is: Next of Kin Executor P.O.A.

Name and Telephone # of Substitute Decision Maker:

 APPLICATION FOR SERVICE page 2

I am applying for: Attendant Outreach Homemaking Supportive Housing

Group Supportive Housing

I was referred by: Hospital Self Other (please describe):

CCAC (case manager, nurse, therapist, other professional)

If CCAC; please provide case manager’s name and telephone #:

PART 2: SUPPORTIVE HOUSING REQUIREMENTS (fill out only if you are applying for SH)

You must require attendant care and an accessible living accommodation to qualify
for supportive housing. Please select type(s) and location(s).

Shared Living Accommodation in Hamilton (for individuals only)

Apartment with attendant services in Hamilton 1 bedroom 2 bedroom

Apartment with attendant services in Burlington 1 bedroom

Apartment with attendant services in Mississauga 1 bedroom 2 bedroom

Apartment setting – How many people will be living with you?

PART 3: CONDITIONS (please check all that apply)

Arthritis Deafness Non Verbal

Blindness Freidrich’s Ataxia Spinal Cord Injury
Cerebral Palsy Head Injury Specify:
Cognitive Impairment Multiple Sclerosis Stroke
Please describe any other condition(s) that affect your ability:

Is your disability likely to be permanent? Yes No

 APPLICATION FOR SERVICE page 3

Onset of illness or injury: Month: Year:

Did your injury / disability result from a workplace injury / illness? Yes No

Did your illness / disability result from an accident? Yes No

Did you receive an insurance settlement or money as a result of your illness / injury?
Yes No

Do you intend to take legal action regarding your illness / injury? Yes No

Do you have funding through CILT (Centre for Independent Living in Toronto)?
Yes No

PART 4: ASSISTANCE NEEDED

Bathing Bladder Care Light Housekeeping

Eating/Drinking Bowel Care Laundry
Toileting Grooming Meal Preparation
Dressing Communication Shopping
Transferring to / from Tracheotomy/Respiratory Assistance with
Wheelchair / Bed Equipment Assistance Medications
Mobility Assistance Other: Arrange Transit

In your opinion, what is the average amount of time required for your personal care
each day? Do not include homemaking.
0 - 1 hrs. 1 - 2 hrs. 2 - 3 hrs. 3 - 4 hrs. 4 - 5 hrs. 5 - 6 hrs.

Who currently provides the assistance you need?

Family Nurse Agency Other (describe):

How many hours a day are being provided?

How would you describe your present condition?

Improving Stable Variable Deteriorating

 APPLICATION FOR SERVICE page 4

PART 5: CURRENT SERVICES (please select the services you currently receive)

Outreach Attendant Services Transitional Living or Rehabilitation Facility

Emergency Response Systems Homecare, Integrated Homemaker, etc.

Family / Friends Vocational Rehabilitation Services

Meals on Wheels Security Checks / Reassurance Services

Nursing Life Skills

Professional Services (e.g. physiotherapy, social work)

Chronic Care Hospital, Nursing Home, or other Health Care Residential Facility

Support Service Living Unit: Group Setting Apartment Setting

Other (describe):

PART 6: Confirmation of Application and the Authorization to Collect, Use and

Disclose Personal Health Information

YES NO
#1 I confirm that the above information is true and correct.

#2 I understand that at least one personal interview is required as part of the

application / assessment process.

#3 I understand that there are criteria for eligibility and wait list prioritization.

#4 I agree that AbleLiving will assess my needs, determine eligibility for

service and develop a service plan with me, if I am eligible.

#5 I agree that AbleLiving may collect and record information, including

information received from hospitals, physicians and other healthcare
professionals for use in planning my service.

#6 I agree that at times AbleLiving may need to exchange information with

service providers and other health professionals involved with my care.
 APPLICATION FOR SERVICE page 5

YES NO

#7 I understand that if I receive services from AbleLiving and then

become unable to direct my care or participate cooperatively for
services, then, AbleLiving may not be able to provide service to me. In
that event, I give my consent to contact my physician and / or
designated others to make the necessary arrangements for
hospitalization and / or alternative care services.

If you answered no to # 5, # 6, # 7 above – please name the persons, community

agencies, and health professionals AbleLiving may not exchange information with:

Specify any service information that cannot be shared with health professionals or
community agencies:

AbleLiving may share information regarding my services with family members and
friends. YES NO

Name the family members / friends with whom AbleLiving may share service
information:

Consent from: Client Other:

Witness to consent: Date:

Signature of Client: Date:

Substitute Decision Maker: Date:

Please provide the name, telephone number and email address of someone we may
contact if we cannot reach you about this application:

Please submit your application through our website www.ableliving.org

or by fax to (905) 692-4622 or by email to khann@ableliving.org or by mail to
AbleLiving Services Inc. Application Administration Centre. 2080 Trinity Church Road,
Binbrook, ON L0R 1C0 (905) 692-4465, Ext: 245.