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Resilience Huron Perth » Application for CHO Services

Application for CHO Services

Please fill out the online form below or download, print, and mail the PDF version of this form.

Application For CHO Services

Name(Required)

S.I.N. #

Current Place of Residence

Street Address Address Line 2 City Province Postal Code

Date of Birth

MM slash DD slash YYYY

Place of Birth

Certificate

Yes

Marital Status

Sex

Languages Other Than English

Religion

Source of Income

ODSP # (If Applicable)

Substitute Decision

Treatment

Finance

Substitute Decision - Name

Public Trustee File #

Health Card #

Health Card Expiry Date

MM slash DD slash YYYY

Referring Source - Name

Referring Source - Phone

Next of Kin

Name

Relationship

Telephone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Health

Health Problems: (Ex. Epilepsy, Diabetes, Heart Disease, Stroke, Surgery, Infections, Etc.)

Yes

No

Details

Physical Handicaps: (Ex. Deformities, Amputations, Prosthesis, Mobility Issues)

Yes

No

Details

Allergies

Yes

No

Allergies to Medication

Allergies to Food

Mental Health

Orientation

Time

Intact

Impaired

Place

Intact

Impaired

Person

Intact

Impaired

Memory

Immediate

Intact

Impaired

Recent

Intact

Impaired

Remote

Intact

Impaired

Other

Halucinations

Yes

No

What are these like? How often do they occur? How do you deal with these?

Concentration

Good

Fair

Poor

Obsessions & Compulsions

Yes

No

Describe

Phobias

Yes

No

Describe

Hypochondriacal Symptoms

Yes

No

Describe

Past Suicide Attempts

Yes

No

Describe

Verbalized thoughts of Suicide

Yes

No

Describe

Self-Harm – Past Attempts

Yes

No

Describe

Verbalizes thoughts of Self-harm

Yes

No

Describe

History of Aggression

Yes

No

Describe

Verbalizes thoughts of Aggression

Yes

No

Describe

History of Sexual Harm to Others

Yes

No

Describe

Verbalizes thoughts of Sexual Harm to Others

Yes

No

Describe

History of Fire Setting

Yes

No

Describe

Delusions

Yes

No

Describe

Depression

Yes

No

Describe

Difficulties with the Law

Yes

No

Describe

History of non-compliance with medication

Yes

No

Describe

Substance abuse issues

Yes

No

Describe

Please indicate signs that person may be becoming ill.

Please indicate any techniques in dealing with person that may be helpful.

Activities of Daily Living

Oral Hygiene / General Daily Grooming

Dependent

Independent

Supervision

Assistance

Bathing

Dependent

Independent

Supervision

Assistance

Dressing Self

Dependent

Independent

Supervision

Assistance

Toileting

Dependent

Independent

Supervision

Assistance

Feeding

Dependent

Independent

Supervision

Assistance

Laundry

Dependent

Independent

Supervision

Assistance

Incontinence

Yes

No

Sleep Difficulties

Yes

No

To Be Accompanied when in Community

Yes

No

Specify level of supervision and reason

Please upload additional documents here, or submit separately:

Copy of Care Plan
Current Medications
Social History
CHO Referral From (download here)

Consent(Required)

I have explained the Community Homes for Opportunity Program to the applicant and I feel that he/she is an appropriate candidate. It is understood that should the applicant be accepted into the CHO Program, I will be expected to continue to be involved in a consultative role.

Consent(Required)

I have discussed the Community Homes for Opportunity Program with my worker and my physician. I understand and agree to abide by the rules and regulations of the program.

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Email

This field is for validation purposes and should be left unchanged.

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Resilience Huron Perth

540 Huron Street
Stratford
Ontario N5A 5T9

(519) 273-1391

info@resiliencehp.ca

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