Greater Victoria Centralized Access to Supported Housing (CASH)

2017 Referral Form

If there are any other details, or if you wish to elaborate on any section of the referral, please attach additional pages as needed.
** Please DO NOT send PowerChart information with referral. **
Please read carefully before completing referral form
Eligibility for Supported Housing:
In order to apply for supported housing through the CASH program, the applicant must:
Be at least 19 years of age
Be diagnosed with a serious and persistent mental illness (Schizophrenia, Bipolar or Major Depressive Disorder) and/or
have serious substance use issues that poses a significant barrier to living independently in market housing
Have a reliable source of income for the purpose of paying rent
Provide written consent (see next page)
The CASH program does not provide access to the following types of housing:
x Subsidizedx EmergencyxFor minors or familiesx Transitional for clientsreleased
xTertiary carex Abstinence basedx Senior’s orAssisted Living from prison

If available; VI-SPDAT score: Vulnerability Assessment Tool (VAT) score: LOCUS score:

Completed by:Date:

Referral Source Information
Referrer’s Name: / Agency:
Title/Relationshipto applicant: / Email:
Phone: / Fax:
Are you the applicant’s primary professional support? / Date you started working with applicant:
CASH staff do not have the capacity to contact and/or support clients. CASH therefore relies on the referrer to maintain contact with the applicant and update CASH if there are any relevant changes in the applicant’s status. If you cannot commit, pleaseidentify an individual or organization that is willing and able to provide ongoing supportto the client:
Name:Agency: Contact info:
REFERRER’S STATEMENT
By signing this application form, the Referrer agrees to what is set out in the statement below. Please read it carefully before signing.
To the best of my knowledge, the information contained in this application is correct.
I have discussed this application with the applicant, explained the role of the CASH staff and application process, and whenever possible, have completed this application together with the applicant.
I understand that CASH will send this application with identifying information only to those agencies to which the applicant has agreed to on the first page of this form.
I understand that all sections of the referral must be completed in order for the referral to be processed by CASH.
ReferrersSignature: Date:
APPLICANTS DECLARATION & CONSENT
We promise that the confidentiality of the information you are providing in this application will be respected in accordance with all applicable legislation. By checking the boxes below and signing this application form, you agree to what is set out in the following statements. Please read it carefully before signing.
I am doing my best to ensure that the information provided in this application is correct.
I understand that in order to determine my eligibility for supportive housing services and to identify programs that could best meet my needs, the Centralized Access to Supported Housing (CASH) staff:
May contact me for further information, to discuss and update me regarding my application. I give my permission for this.
Will contact and share information with the Referrer (if any) who signs the Referrer’s Statement on page 1. I give my permission for this.
Contact and share information with the service providers listed on this application form (e.g. psychiatrist, physician, other service providers and contacts) I give my permission for this.
Contact and share information with the Ministry of Social Development (MSD) for purposes of establishing criteria for Streets to Homes program if applicable.
I understand that this application will be processed by the CASH Office; I give my permission for this.
I understand that the information in this application will be shared by the CASH Selection Committee; which is made up of the following organizations: Island Health, Pacifica Housing, Our Place Society, Victoria Cool Aid Society, Island Community Mental Health, the Salvation Army (ARC), the Society of Saint Vincent de Paul (Vancouver Island) as well as other organizations as they sign the CASH Memorandum of Understanding; I give my permission for this.
I understand that if I am eligible for supportive housing services, this application will be sent to those who are providing the service. I give my permission for this.
I understand that the service provider who receives my application may contact and clarify information with the Referrer (if any) who signs the Referrer’s Statement on page 1. I give my permission for this.
Print Name: Applicant Signature:
If you have chosen not to consent to any of the above statements, please explain:Date:
Section A – Applicant General Information
Last Name: / (Legal) First Name: / Aliases:
DOB: / Gender identity: / Does applicant identify as an Indigenous person of Canada?
Current Address: / Phone/Message #: / How long in Victoria:
Relationship Status:
 Single Couple/Married
Other Dependents / Who does applicant presently live with:
SelfSpouse/Partner Non-Relatives
Parents Relatives Children - Age:
INCOME/FINANCIAL INFORMATION (check all that apply)
 Income Assistance: IA PWD PPMB
Canada Pension Plan (CPP)
Employment Insurance
 Old Age Security (OAS)
Employment (Please indicate employer):
Other:
Applicant has applied for one of the aboveNoYes; application status/date:
PoA or Public Guardian & Trustee involved: NoYes; please provide documents / Amount:
Amount:
Amount:
Amount:
Amount:
Amount:
Total Income:

Section B – Health Issues and Support Needs

Mental Health issues:NoYesIf yes,diagnosis:

Diagnosed by:

Medication compliant: NoYes
Suicide Attempt in the past 2 years:NoYesIf yes, date of last attempt:
Self-harm behaviour in the past 2 years: NoYesIf yes, date of last incident:
Substance use issues:NoYes;UseMisuseAbuseControlled
If yes, list Substance(s):
Frequency of use: Daily  Weekly Monthly  Sporadically
Cognitive issues: No  Yes Diagnosis (developmental disorder, dementia, brain injury etc.):
Physical health issues: NoYes If yes, provide details:
Can manage conditions on their own? No Yes
Can client do stairs unassisted? No Yes If yes, how many:
Does client use a mobility aid? No Yes If yes, provide details:

SAFETY RISKS

We ask the following questions to determine if there are any safety or risk issues of which we should be aware. Answering any of the questions below will NOT exclude the applicant from service. We know that these are sensitive questions and appreciate you answering them.
History of aggression/ violence No Yes If yes, please explain:
Lack of attention while smoking NoYes Inappropriate sexual behavior No Yes
Mishandling fire/fire setting  NoYesDestruction/abuse of property  No Yes
Guest issues No Yes Drug dealing No Yes
Issues with collecting things (hoarding)NoYesEasily taken advantage of No Yes
Process Addiction No YesInvolved in sex trade No Yes
(non-chemical addiction such as gambling, internet)

LEGAL INVOLVEMENT

Current or past involvement in criminal justice system: No Yes
If yes, please provide details (Type of offence, date, sentence, probation period):
Probation officer (name and contact information):
TYPE(S) OF SUPPORT NEEDED:Please check off level of support needed and provide comments.
Managing medication:  None  Some  A lot Comments:
Managing money:  None  Some  A lot Comments:
Doing household chores:  None  Some  A lot Comments:
Meals/grocery shopping:  None  Some  A lot Comments:
Hoarding support:  None  Some  A lot Comments:
Using community resources: None  Some  A lot Comments:
Crisis management:  None  Some  A lot Comments:
Hygiene assistance/ prompting:  None  Some  A lot Comments:
OTHER SERVICE PROVIDERS INVOLVED WITH APPLICANT: (e.g. physician/psychiatrist, Case Manager, ACT/VICOT, outreach worker)
Name:Contact (Phone/Email):

Section C - Housing

CURRENT LIVING SITUATION
 Supported Housing Non-profit housing Market Rent No fixed address
 Couch Surfing  Hospital Hostel/Shelter  Tertiary Care
 Correctional Facility Treatment Facility Other:
How long in this living situation? (in days, months, or years)
Is there any length of stay deadline in current living situation? NoYes, date ending:
Why does applicant need or want to move?
What are the main barriers to living in market housing?
Have you applied to BC Housing No Yes If yes, date application submitted:
Status of application(s):
Other housing agencies?  No Yes If yes, Agency (s):
HOUSING HISTORY
Please indicate Living Situations (correctional facility, treatment/detox, shelter, NFA, couch surfing, market housing, supported housing, non-profit housing, hospital, other), datesof residency and respectivereason for leavingfor the past 3 years:
Year / Living Situation / Dates of residency / Reason for leaving
2016
2015
2014
Prior to 2013:
If not indicated above, has the applicant ever lived in supported housing? No Yes
If yes, name(s) of building(s) and dates of residency:
HOUSING PREFERENCES:What level of housing would be the best fit for applicant?
 Market rent housing with outreach support (Streets to Homes) /  Low support, staff available daily on- or off-site
 Low barrier/ tolerant housing, light to moderate supports /  Ages 55+, low barrier/tolerant supported housing
 Mental Health Recovery focused housing, 24/7 staffing /  High support/low barrier, 24/7 staffing, secure entry
 Group home setting with intensive mental health supervision (Licensed Care)

Why would applicant benefit from the housing identified above?:

Goal of supported Housing:
Please identify any specific buildings applicant IS interested in:
Please identify any specific buildings applicant is NOT interested in:

FAX COVER SHEETCONFIDENTIAL

Date:No. of Pages (including cover):

TO: Centralized Access to Supported Housing (CASH)______

Fax #: 250-519-3481 Phone #: 250-519-3595______

FROM:Sender’s name and contact information

Name: ______

Location: ______

Fax #: ______Phone #:______

Checklist:

☐pg 1:Referrer statement signed – supported housing eligibility reviewed and checked off

☐pg 2: Applicants declaration & consent – all boxes checked off (cannot process if partially complete)

☐pg 34: Completed CASH Referral form – all sections filled in (with n/a if not applicable)

☐pg 5: Fax Cover Page

☐#__ ofadditional pages attached (as needed) – no PowerChart information

**Incomplete referrals cannot be processed and the file may be closed**

Message:

Confidentiality Warning

The attached material is intended for the use of the individual or institution to which this fax is addressed and may not be used, disclosed, copied or distributed to other unauthorized persons. This material may contain confidential or personal information that may be subject to the provisions of the Freedom of Information and Protection of Privacy Act. If you receive this transmission in error, please notify the Information Access & Privacy Office immediately at 250-519-1870,1-877-748-2290 or . VIHA will arrange to have the material returned to our office. Thank you for your cooperation.

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