Vista Centre

Application For Service

First Name: (required)

Last Name: (required)

Gender: Male Female

Birth Date (yyyy/mm/dd):

Health Card #:

Version #:

Expiry Date (yyyy/mm/dd):

Address:

Apt #:

City:

Province:

Postal Code:

Home Phone:

Marital Status: Single Married Divorced

Current Living Situation: Alone With Others - specify

Accommodation:

House
Group Home
Apartment Building
Long Term Care Facility
Supportive Housing
Rooming House
Hospital
Other

Citizenship: Canadian Permanent Resident Other

Are you a resident of Ontario: Yes No If yes, how long?

Language Spoken:

Interpreter Required: Yes No

First Nation Band Affiliation:

Status Number with Dept. of Indian Affairs:

Date of Injury:

Cause of Injury: (e.g. anoxia, assault, motor vehicle accident, fall, etc.)

Emergency Contact

First Name:

Last Name:

Relationship:

Email:

Address:

City:

Province:

Postal Code:

Home Phone:

Work Phone:

Other Contact

First Name:

Last Name:

Relationship:

Email:

Address:

City:

Province:

Postal Code:

Home Phone:

Work Phone:

Referring Agent (who is making the request):

Name of Agency:

Name:

Phone:

Email:

Relationship:

Contact Person: Yes No

Type of Service Requested: Residential Day Services Outreach Services Other

Treatment History Including Current Services

Program/Facility/Hospital:

Dates Involved (yyyy/mm/dd):

Contact and Phone #:

List Of Services You Have Applied For From Other Agencies

(e.g. Vocation Rehabilitation, Addiction Services)

Facility/Program:

Contact and Phone #:

Status of Application:

Please note that medical, attendant care, rehabilitation and vocational reports are required: Neurosurgery, Neuropsychology, Speech Therapy, Physiotherapy, Occupational Therapy, Social Work, Psychology, Psychiatry, Assessment and Discharge Summaries. If you have copies of these reports please attach to the application.

Personal Information

Seizures: Yes No If yes, describe:

Wheelchair: No Manual Motorized

Transfers: Yes No If yes, describe:

Assistive Devices: Yes No If yes, what is needed:

Attendant Care: Yes No If yes, describe:

Supervision or assistance with walking: Yes No If yes, does it apply to: Level Surfaces Stairs Both

Communication Issues: Yes No If yes, describe:

Other Physical Conditions: (allergies, heart conditions, diet restrictions, etc) Yes No If yes, describe:

Pre-Injury History of Substance Abuse: Yes No History Not Available

Current Substance Abuse: Yes No Not Known

Substance Abuse Treatment Recommended: Yes No

Previous Psychiatric History: Yes No If yes, describe:

Current Psychiatric Status:

Psychiatric Consult Notes: Included Report to Follow Not Available

Education: Highest grade/level attained:

If in school, name of school:

Name of Last Employer:

Positon:

How long were you in this position?

Financial Information

Check Source Of Income:

Old Age Security (OAS)
Ontario Disability Support Program (ODSP)
Ontario Works (OW)
Workplace Safety Insurance Board (W.S.I.B.)
Canadian Pension Plan (C.P.P.)
Long Term Disability (private)

Lawyer's Name:

Company:

Phone:

Insurance Adjuster Name:

Company:

Phone:

Rehabilitation Case Manager:

Company:

Phone:

Other souces of Income:

Insurance Settlement
Structured Settlement
Inheritance
Part Time Employment
Full Time Employment
Income Generating Assets

Amount of income per month:

Do you have direct access to your income? Yes No

If no, Name and Phone Number of Substitute Decision Maker/Power of Attorney:

What is 1 + 9? (anti SPAM question)

Vista Centre

Tel (613) 234-4747
Fax (613) 234-3625

info@vistacentre.ca

211 Bronson Avenue, Suite 214
Ottawa, Ontario K1R 6H5 Canada