Ryandale Referral form

Referral Form

Referrals are accepted from social agencies as well as self referred clients.
Ryandale Transitional Housing focuses on long-term, sustainable solutions to homelessness. Ryandale offers affordable accommodation for up to one year to people who
- identify as male
- are over the age of 24
- are clean and sober for a minimum of 2 months
- have no history of violent crime against people or property and have no previous sexual assault and/or child endangerment/abuse convictions or have been convicted of arson
- are at risk of, or are experiencing, homelessness.
- Applicants should have demonstrated the desire and ability to achieve independent living. If your client does not meet these intake criteria, please do not apply.
The Transition Houses offer support with life skills to assist with permanent housing, life management and positive community involvement. Staffing levels differ between locations. Each occupant has a private, furnished room and shared access to a kitchen and bathroom. Internet and telephone access are provided. Ryandale no longer offers emergency short-term shelter.

Ryandale is a non-judgmental transitional housing provider. We encourage residents to take responsibility for their actions, both in the past and in the future. During the application and interview phase, an applicant will be asked questions relating to
- drug and alcohol use
- physical and mental health status,
- previous criminal charges.
- Giving misinformation, or not providing a complete history when asked during the application process, may result in rejection of the application.
*This referral does not guarantee acceptance. Once a referral has been received, a staff member will contact the applicant to set up an interview. When a decision has been made, the applicant will be informed.
Date*

MonthDayYear
In order to ensure compliance with PHIPA and/or your own agency's policy regarding the release of confidential information, please check below that the client has been advised regarding the uses and limits of sharing information.*

I agree with the aboveI disagree with the above
*Ryandale may share information regarding a resident with other agencies in compliance with appropriate release of information requirements.
Referring Agency*
If other please enter here
Referrers Name*

First NameLast Name
Referrers Email*
example@example.com
Referrers Phone Number*
Please enter a valid phone number.
Relationship to Referree
Is the applicant aware of this referral*

yesno
Applicant Contact Information

Please complete all sections of the form when possible. please do not leave any items blank
Name*

First NameLast Name
Alias (AKA)

First NameLast Name
Date of Birth*

MonthDayYear
Gender*
If other please enter here
Phone Number
Please enter a valid phone number.
Email
example@example.com
Marital Status*

SingleMarriedDivorcedWidowed
What Race do you identify as*

White/CaucasianIndigenousBlackAsianTwo or more racesPrefer not to say
Clients Current Address

Address

Indirizzo Riga 2

CityNazione / Provincia

Postal Code
If you do not currently have a phone or are hard to reach, is there someone you are in regular contact with that we can call to reach you?
Name - Alternate Contact

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship
Can a message be left at the number provided?

yesno
Source of Income
Source of Income*

Ontario Disability Support Program (ODSP)Ontario Works (OW)Employment Insurance (EI)EmployedWorkers CompensationNoneCPPOther
If other please enter here
Homelessness Status
Are you currently homeless?*

yesnoprecariously housed/at risk
Are you at risk of becoming homeless?

YesNo
If Yes Explain
What is your current living situation?*

Couch surfingLiving in a ShelterLiving with FamilyLiving with room mateAbout to be evictedLiving RoughIn TreatmentIn HospitalOther
If Other Explain
Have you been released from a provincially funded institution or service system (prison or hospital?)

YesNo
Please provide any additional information you feel we need to know about your housing situation:
Additional information

Housing Requirements and Medical Information

Do you have the following ID's ?*

	Yes	No
Health Card
SIN
Birth Certificate
Drivers License
Ontario ID Card
Status Card

Do you have a Health care provider?*

yesno
Health Care Provider
Do you have any physical health issues/allergies*

yesno

Do you have addictions issues?*

yesno
How long have you been clean/sober?
What steps did you take to achieve sobriety?

28 + Days in Treatment FacilityDetox12 step programsOther
If other please explain
What is your sobriety/clean date

MonthDayYear
Do you need a wheelchair accessible unit*

yesno
Are you a victim of domestic abuse*

yesno
Do you need support services*

yesno
Do you have a developmental disability?*

yesno
Do you have a mental health diagnosis?*

yesno
Health Information

Please answer the following related to mental health and substance use disorder*

	Yes	No
Do you have current or past mental health experiences
Have you been formally diagnosed with a mental illness?
Have you ever experienced psychosis
Do you or have you had an eating disorder
Have you been hospitalized due to a mental health issues
Are you designated as alternative level of care (ALC)
are you currently on a community treatment order?
Do you have a concurrent disorder (substance use and Mental illness)?
Do you have dual diagnosis (developmental disability and mental health)
Do you have a neurological disability or disorder? (head/brain injury, epilepsy, parkinsons)
Do you have an intellectual disability?

If other please explain
Please explain allergies
Relevant Medical History please attach medication records and information pertaining to the diagnosis
Relevant Medical Reports

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Please list all medications, including any MAT (Methadonem,Suboxone,Subsolv, Sublicade, Vivitrol etc) you are currently prescribed and the dosage in milligrams.
If you are on MAT medications where will you be receiving these medications?
Are you prescribed any "Other" Controlled Substances for example (Benzodiazepines, Amphetamines, etc) Please list.
Have you served in the military?*

yesno
Have you been in touch with VAC?

yesno
Are you currently or in the past been involved with the criminal justice system

YesNo
Do you have a criminal record?*

yesno
If yes, please explain here:
Please upload a copy of criminal record

*Ryandale can not accept applicants with a record of violent crime against people or property
Cancelof
Please complete the following if you have current legal involvement

Pre-Charge DiversionCourt Diversion ProgramAwaiting Fitness assessmentIn Community on own recognizanceAwaiting trial (with or without bail)Unfit to stand trialAwaiting Criminal responsibility assessment (NCR - not criminally responsible)ORB detained community access (Ontario Review Board)On ProbationORB conditional discharge (Ontario Review Board)IncarceratedOn ParoleCharges WithdrawnConditional SentenceStay of proceedingsRestraining OrderAwaiting SentencePeace BondNot Criminally ResponsibleSuspended SentenceConditional Discharge
What supports are you currently accessing?*

FoodHousingHealth CareMental HealthDentalCommunity Groups12 Step ProgramsEmployment ServicesOther
If other please enter here
Do you have personal supports? (Friends, Family, Cultural?)
Would you need assistance from the fire department to leave the building in case of fire or other emergency?

YesNo

For each area below, please check the box that best describes how you feel about social supports:

	I can do this on my own	I’d like some help	Not sure / Need more info
Developing positive relationships
Meeting new people
Peer Support

For each area below, please check the box that best describes how you feel about Health and Wellness

	I can do this on my own	I’d like some help	Not sure / Need more info
Diabetes Education
Self managing medication
Dealing with drug or alcohol abuse
Wellness Recovery action planning
Physical Health and Education
Time Management
Self Care

For each area below, please check the box that best describes how you feel about Food and Nutrition

	I can do this on my own	I’d like some help	Not sure / Need more info
Nutrition and diet information
Grocery Shopping
Meal Prep
Making good healthy food choices

For each area below, please check the box that best describes how you feel about Finances

	I can do this on my own	I’d like some help	Not sure / Need more info
Managing financial responsibilities
Budgeting
Credit Counseling
Financial Literacy
Bank accounts

For each area below, please check the box that best describes how you feel about Legal

	I can do this on my own	I’d like some help	Not sure / Need more info
Do you require support understanding your rights in the justice system?
Self Advocacy Skills
Tenant Rights

For each area below, please check the box that best describes how you feel about employment and education

	I can do this on my own	I’d like some help	Not sure / Need more info
Understanding English - reading and writing
Employment/Career possibilities
High School Completion
Job Training Programs
Going to College

For each area below, please check the box that best describes how you feel about daily activities

	I can do this on my own	I’d like some help	Not sure / Need more info
using city transportation (buses)
Structuring your day
Daily living skills
Looking after your home
Going to College

For each area below, please check the box that best describes how you feel about Cultural Activities

	I can do this on my own	I’d like some help	Not sure / Need more info
Connecting with the land
Drumming
Elder
Sacred Medicine
Smudging
Ceremony

We ask the following to determine if there are safety/risk issues we should be aware of. Answering the questions below will NOT exclude you from service. We know these are sensitive questions and we appreciate you answering them. If you have any recent (last 3 years) history of the following please let us know below

If you struggle with any of the items listed, please indicate how long it has been since the last incident.

	No	6 month	6m-1year	1-3 years	over 3 years
alcohol/Drug use that causes you harm
Thoughts of suicide
Suicide attempt
Self Harm
Lack of attention while smoking
Mishandling Fire/Fire Setting
Assault by you - Physical
Assault by you - Sexual
Assault by you - Verbal
Problems with Anger Management
Inappropriate Sexual Behavious
Destroying/Abuse of Property
Gambling
Issues with Collecting items
Problems with Violence
Accidently started fire in your home
Were you assaulted verbally, physically m sexually

Emergency Contact Information
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Reason for Referral
Treatment Required
Other Information
Please click 'Browse' to select and upload any additional relevant files

Cancelof
Consent to Disclose Personal Information

Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA) Completing this form authorizes the release of my personal information to Ryandale Shelter for the Homeless (Ryandale Transitional Housing)

I understand the purpose for disclosing this personal information to Ryandale. I understand I can chose to not complete this consent form.
Ontario Benefits Support Worker Name   First Name   Last Name
Home Base Housing Support Worker   First Name   Last Name
OPD/PBC Support Worker   First Name   Last Name
AMHS Support Worker   First Name   Last Name
Family Doctor  First Name   Last Name
Psychiatrist/PsychologistFirst Name   Last Name
Kaymar Support Worker   First Name   Last Name
Kingston Public Health Support Worker   First Name   Last Name
Other Support Worker   First Name   Last Name
Power of AttorneyFirst Name   Last Name
Signature*

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Should be Empty:

	Yes	No
high blood pressure
Do you have allergies
Diabetes
Heart issues
Chronic Illness (Guillane barre, lyme disease, other)
Other

Referral Form

Applicant Contact Information

If you do not currently have a phone or are hard to reach, is there someone you are in regular contact with that we can call to reach you?

Source of Income

Homelessness Status

Additional information

Health Information

Emergency Contact Information

Reason for Referral