Application To Concurrent Disorder Support Services (Cdss) Page 2
ADVERTISEMENT
1
2
3
4Note: Date is
Day/ Month/ Year
Application to Concurrent Disorder Support Services (CDSS)
Date applic rec’d: ___________________ ID #: _______________ Priority Access: Serv. 1 Y / N; Serv. 2 Y / N
Client first name: _____________________________________ Last name: _______________________________
Current address/ location: ____________________________ Home address: ________________________ NFA __
Phone: __________________________________ Alt. phone or contact: __________________________________
Date of birth
Age _____ Aboriginal? Y __ N ___ Race/Culture _____________
(D/M/Y): ____________________________
English? Y ___ N ___ Need translator? Y ___ N ___ Language(s) ____________________ Veteran? Y ____ N____
Ref. source: Name ________________________ Agency ____________________ or check (√) Self ___ Friend ___
Office phone: ______________________ Cell: ________________________ Fax: __________________________
Email address: ___________________________________ Applicant’s OHIP #: ___________________________
Demographics: Check (√) the client’s circumstances at the time referred.
Gender
Marital Status
Income
Education
Male
No income
Not in school now
Single
Female
Employment
In school: Specify
Separated/divorced
LGBTQI, Two
Family
type of school
Domestic partner
Spirited (Specify)
Private insurance
_________________
Married
Gov’t subsidy: Specify
____________________
Highest completed
Widowed
____________________
_________________
grade of education:
Unknown
Other
_________________
Employment
Current Residence
Living Arrangement
Legal Issues - Past Year
No employment
Homeless on street
Lives alone
No legal problems
Casual, sporadic
Shelter/hostel
With partner/spouse
Awaiting sentencing
Works independently
Room & board
With children
Awaiting trial/bail
Supportive housing –
Assisted in work
With parents
Conditional discharge
Consumer business
assisted
With other family
Court diversion pgm
Supportive housing –
Sheltered workshop
With non-relatives
Crim. response assess
Volunteer (not paid)
congregate (group)
Other
Fitness assessment
Other activity
Private house/apt.
Incarcerated
Citizenship
(school, retired,
Social/subsidized
On parole
Canadian citizen
homemaker, etc.)
housing
On probation
Landed immigrant
Correctional facility
Pre-charge diversion
Refugee status
Other:
Charge: __________
Unknown/ Other
Reason for referral: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Can you as referring worker provide case facilitation during the period of CDSS service? Yes ___ No ___
Client request for men, women, youth or senior services – check (√) up to 2 services:
Addictions medicine & psychotherapy
Primary care
Addictions stabilization/ withdrawal/ treatment
Psychiatric assessment
Case management
Neuro-psychological assessment - brain injury
Counseling
(Request CHIRS Referral Form)
Women’s counselling for trauma: group/ indiv.
Safe bed
Seniors’ outreach/ services
Housing support/ assistance in applying
2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business