APPLICATION FORM. Eligibility. Application Process

Transcription

1 APPLICATION FORM Eligibility 1. Applicants must be able to manage most or many daily tasks independently, arrange, manage and direct their own care and be responsible for decisions about day-to-day activities. 2. Applicants should be 65 years of age or older. Applicants under 65 years of age may qualify for some communities. 3. Must be Canadian citizen or Permanent Resident (landed immigrant). Application Process 1. Complete all sections of the application form. 2. Provide a copy of your Notice of Assessment (processed Income Tax) from the most recent tax year. If you cannot locate yours, call Canada Revenue Agency at Ask your doctor to fill out the Medical Report. Please note that if there is indication of memory loss, a memory test (MOCA or MMSE) will be required. 4. Submit the application form, NOA and Medical Report through fax: , mail: 804, 7015 Macleod Trail SW, Calgary, AB T2H 2K6 or placement@silvera.ca. 5. Once your application is received, our Placement Team will review the application and supporting documents to ensure they are complete. If information or documentation is missing, you will be notified. 6. Upon receipt of your completed application, a member of the Placement Team will contact you to schedule an in-person meeting to review your application. This discussion will assist in determining eligibility of the applicant. If determined that you may be eligible, your name will be added to our waiting list. 7. When a suite becomes available, you will be called for an intake interview. Please note that your needs will be re-assessed at this time to ensure they can be met within the services we can provide. 1

2 This confidential information is being collected under the authority of the Alberta Housing Act and will be used to determine eligibility of applicants, need and allocation within the housing programs at Silvera for Seniors. Collected personal information is protected from unauthorized access, collection, use and disclosure in accordance with Alberta privacy legislation and can be reviewed or corrected upon request. Questions regarding the collection of personal information can be directed to: FOIP Coordinator Silvera for Seniors Phone: / Fax: / contact@silvera.ca APPLICANT CONTACT INFORMATION Last Name: First Name: Middle Name: Also known as: Date of birth: Age: Current Address: Phone #: CO-APPLICANT CONTACT INFORMATION Last Name: First Name: Middle Name: Also known as: Date of birth: Age: Please note that a separate application will need to be submitted for the co-applicant. If you have someone helping you filling out this application, please complete this section. Name: Relationship: Current Address: Phone #: Permission to contact or discuss your information: Yes No Applicant Signature: 2

3 APPOINTEE INFORMATION (if applicable) Power of Attorney Enduring Power of Attorney ( enacted / acted) Legal Guardian Public Trustee Personal Directive If you check any of the boxes above, we may need to discuss the nature of the relationship and have supporting documentation provided. CITIZENSHIP & MIGRANT STATUS What is your current citizenship and immigration status? Canadian citizen Permanent resident (Landed immigrant) Other: How long have you been in Canada? How long have you been in Calgary? GENERAL INFORMATION What is your primary language? English French Other Is an interpreter required? Yes No If yes, do you have access to an interpreter? Yes No Why do you want to move to Silvera? Affordable Housing 24/7 non-medical staff Recreational Activities (please list any special interest): Housekeeping Services Meals Other (please specify): How did you learn about Silvera for Seniors? 3

4 What is the reason you are considering housing with Silvera? Have you ever lived at Silvera before? Yes No If yes, please list reason(s) for leaving: Have you ever used a housing supports program? Yes No INCOME (please check all that apply) Annual Income from Line 150 of most recent NOA $ Please attach a copy of your most recent Notice of Assessment from Canada Revenue and Taxation. AISH $ Old Age Security $ Alberta Seniors Benefits$ Guaranteed Income Supplement $ Canada Pension Plan $ Other Pension $ Employed $ Other: $ ASSETS Property: $ Investments: $ Savings: $ Car: $ Other: $ If you own a car, would you require a parking space? Yes No CURRENT LIVING SITUATION Own house Rented Shelter Treatment facility Long Care Facility Staying with friends 4

5 Transitional Housing Hospital Staying with family Other ( please specify): Is there any length of stay deadline in your current living situation? Yes No If yes, what is the date your living situation will end? Please provide supportive documentation if applicable. SUPPORTS REQUIRED (Please use an X to describe yourself in the following areas) Task / Assistance Required No Assistance Some Assistance Full Assistance Comments Meals Housekeeping Laundry Bathing Finances Personal shopping Arranging transportation Dressing Walking Making appointments Managing hearing aid Managing stairs Accessing help Evacuating a building Managing electronics (phone, TV remote, etc) 5

6 MEDICAL INFORMATION Do you have Alberta Health Care number? Yes No Do you have a physical health condition? Yes No If yes, please provide further information: Do you have incontinence? Yes No If yes, do you use incontinence products? Have you had any falls in the past year? Yes No If yes, please provide further details: Do you require a mobility aid? Yes No Do you require specialized housing accommodations due to a disability? Yes No If yes, please explain: Do you have memory loss? Yes No (If yes, please provide copy of a recent memory test completed by a medical professional) Have you ever had any confusion concerns? If yes, please provide further details: Are you taking medications at the present time? Yes No Do you require assistance/reminders to administer your medication(s)? Yes No N/A Do you access home care? Yes No If yes, please provide further information (for what kind of supports, how often, etc): 6

7 Do you have any severe allergies? Yes No Do you require assistance with a special diet? Yes No N/A Are you on oxygen? Yes No Do you smoke? Yes No (Please note that all Silvera buildings are smoke-free) Do you have a mental health condition? Yes No If yes, what are the symptoms? Do you have coping strategies? Yes No If yes, please list them: HOUSING OPTIONS - Please list below the communities you would prefer to be considered for. Please note we may explore other options based on availability as well as your needs. Check our website at APPLICANT'S ACKNOWLEDGEMENT I understand and agree that this application is neither a contract nor a reservation for residence. Nothing contained in this document obligates or entitles me to a suite at Silvera for Seniors until a Tenancy Agreement has been signed by all parties involved. Signature of Applicant: Date of Application: 7