mhopapply – Freedom Housing Inc.

Background: FREEDOM HOUSING INC. (the “Organization”) is a non-profit organization that promotes wellness and independence by providing low-cost transitional housing for vulnerable persons, such as individuals with mental health and/or addiction problems. The transitional housing is coupled with services that offer structure, support and supervision to help occupants gain or regain valuable and meaningful roles in the community. The Organization realizes that many individuals who reside outside our houses can also benefit from these services, hence the creation of the Mental Health Outreach Program.

Participant Details:

First Name:

Last Name:

Email:

Street:

Apt:

City:

Postal Code:

No Fixed Address

Participant on:

Referred By:

Other:

Organization Name:

Referee Name:

Referee Phone:

Referee Fax:

1. Participant Inclusion Criteria (please initial and provide details to AT LEAST one and all other that apply):

1.1 Diagnosed mental illnesses that seriously impair their functioning in community living and currently treated by a physician.

Select all that applies - Multi-select enabled:

1.2 Other:

Psychiatrist Name:

2. Prescribed Medication:

a.

b.

c.

d.

e.

f.

g.

h.

i.

j.

3. Intractable (i.e., persistent or very recurrent) major symptoms.

Select all that applies - Multi-select enabled:

Other:

Further Details:

4. Coexisting past, present or high risk of substance abuse.

Select all that applies - Multi-select enabled:

Other Details:

5. Clients with significant impairment.

Select all that applies - Multi-select enabled:

Further details:

6. Goals of care (To be filled by Referee and Patient)

Select all that applies - Multi-select enabled:

Further details:

Is the participant enrolled in any other mental health program?

Other mental health program name:

Is the participant attending any counselling?

Counselling name:

7. Consent to release personal or healthcare information

Legal Text:

I am authorized to disclose all the above personal and health information to Freedom Housing Inc. I will inform Freedom Housing Inc. in writing if the participant wishes to revoke this consent at any time.