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Service Information
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Service Information

Service:

Attendant Outreach
Organization: Nucleus Independent Living
Description:

Attendant services are provided by qualified Personal Support Workers and include non-medical personal support and essential homemaking services that are available on a pre-scheduled basis only.

Referral Options:

What attendant services is the applicant requesting from Nucleus?*

Personal care (including bathing, dressing, personal hygiene, bowel/bladder routines)

Assistance with transfers

Meal Preparation and/or assistance with eating

Assistance with adaptive equipment or communication devices

Light housekeeping (only available if applicant is also in need of and is receiving personal care by Nucleus)

Other

Required: choose at least one option

Days of the week that service is required

Monday:

Morning

Afternoon

Evening

Tuesday:

Morning

Afternoon

Evening

Wednesday:

Morning

Afternoon

Evening

Thursday:

Morning

Afternoon

Evening

Friday:

Morning

Afternoon

Evening

Saturday:

Morning

Afternoon

Evening

Sunday:

Morning

Afternoon

Evening

Eligibility:*

Are these eligibility requirements met?

Client is living with a permanent physical disability

Yes

No/Unsure

Warning: Submission may be denied, please provide more details.

This field is required

Minimum Age: 16 yrs

Yes

No/Unsure

Warning: Submission may be denied, please provide more details.

This field is required

Client Information

Client Name:*

First name*

This field is required

Family/Last Name*

This field is required

Personal Pronouns:

This field is required

Email Address:

Email (Confirmation and reminder emails will be sent here)

This field is required

Phone:

Primary Phone*

This field is required

Secondary Phone

This field is required

Address:

Unit/Suite #

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Street # & Street Name

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City

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Province/State

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Postal/Zip Code

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Select location on a map

Gender:

Male

Female

Undisclosed/Other

This field is required

Date of Birth:*

Day

Month

Year

Age: ( corrected)

This field is required

Ineligible - You have specified age of .

The age eligibility requirements for this service is:

Warning: Submission may be denied.

Client Health Card Number:*

Client Health Card Number*

This field is required

Family Doctor:

Family Doctor Name

This field is required

Family Doctor Phone #

This field is required

Conduct Appointment With:

Client

Alternate Contact 1

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Alternate Contact

Relationship to Client :

Spouse

Son/Daughter

Sibling

Parent

Friend

Other

This field is required

Alternate Contact Name:

First name

This field is required

Family/Last Name

This field is required

Alternate Contact Email Address:

This field is required

Alternate Contact Info:

Primary Phone

This field is required

Referrer

Relationship to Client:

Spouse

Son/Daughter

Sibling

Parent

Friend

Legal Guardian

Other

This field is required

Referrer Name:

First name

This field is required

Family/Last Name

This field is required

ReferrerEmail Address:

This field is required

Referrer Info:

Primary Phone

This field is required

Health Information

Diagnosis:

Primary Diagnosis

This field is required

Risk Factors:

Is this condition likely to

Gradually Deteriorate

This field is required

Improve

This field is required

Rapidly Deteriorate

This field is required

Remain stable

This field is required

Other

This field is required

Services:

What other services have been initiated?

Other

This field is required

Relevant Medical History:

Type of physical disability and describe how this condition affects the ability of the applicant to complete activities of daily living

This field is required

Additional Information

Where will services be delivered:

Indicate one of: Home, Work, School:

Any other disabilities or medical conditions that may affect delivery of attendant services:

(i.e. Visual/hearing impairments, epilepsy, diabetes, cognitive difficulties):

Assistive devices used (please list all):

Consent

Is the patient aware of the referral to Attendant Outreach and has given consent?

Yes

Consent provided by:

Consent obtained by:

This must be to continue

This field is required

clear consent values

By clicking "Finish", you agree to send this personal information to Nucleus Independent Living online.

You agree to these Terms and Conditions and Privacy Policy, which govern how your personal information is kept safe.

Notifications:

Send confirmation, change & reminder messages to < name > < email >

Yes

To receive notifications, please select Yes.

Submission complete

The information has been submitted to Nucleus Independent Living, but you have some steps left:

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Summary

Reference #: -

Registrant:
Organization:

Nucleus Independent Living

Service:

Attendant Outreach

Inquiry Phone:

1 (905) 822-2273

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Grey area: Service delivery area

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