G. Community Supports Please provide information below about the community supports currently received: Contact name/ Agency Phone number Length of Involvement 1 ( ) 2 ( ) 3 ( ) H. Physical and Mental Health Information Mental Health: How long have you been challenged by Mental Health issues: (ie: number of years)? Have you received a formal diagnosis? Yes No Don’t Know If yes, what is the diagnosis? 3. Do you have a psychiatrist? 4. Have you been to hospital emergency department in the past two (2) for Mental Health reasons: Yes No If yes, how many times have you used emergency services in the past two (2) years? 5. Have you been admitted to hospital due to Mental Health issues in the past two (2) Years? Yes No If yes, please provide the number of times hospitalized and number of days in hospital. Location of hospitalization: 6. Has the applicant had thoughts of suicide in the last Yes No 7. Has the applicant attempted suicide in the last 12 months? Yes No Physical Health: 1. Do you have any physical health conditions or challenges (hearing impairments, physical limitations, medical conditions or allergies) Yes No If yes, please describe. Will these affect your housing options? 2. Do you have a family doctor? Yes No I. Additional Comments Below, please provide any additional comments you feel are important for processing of this referral:
G. Community Supports Please provide information below about the community supports currently received: Contact name/ Agency Phone number Length of Involvement 1 ( ) 2 ( ) 3 ( ) H. Physical and Mental Health Information Mental Health: How long have you been challenged by Mental Health issues: (ie: number of years)? Have you received a formal diagnosis? Yes No Don’t Know If yes, what is the diagnosis? 3. Do you have a psychiatrist? 4. Have you been to hospital emergency department in the past two (2) for Mental Health reasons: Yes No If yes, how many times have you used emergency services in the past two (2) years? 5. Have you been admitted to hospital due to Mental Health issues in the past two (2) Years? Yes No If yes, please provide the number of times hospitalized and number of days in hospital. Location of hospitalization: 6. Has the applicant had thoughts of suicide in the last Yes No 7. Has the applicant attempted suicide in the last 12 months? Yes No Physical Health: 1. Do you have any physical health conditions or challenges (hearing impairments, physical limitations, medical conditions or allergies) Yes No If yes, please describe. Will these affect your housing options? 2. Do you have a family doctor? Yes No I. Additional Comments Below, please provide any additional comments you feel are important for processing of this referral:
ASH-Application-2017.docx