Service Information

Supports for Daily Living: Central Registry Intake
Organization: Central Registry > Nucleus Independent Living
Description: Provides assistance in connecting clients with a variety of services from local community agencies. Services include in-home personal support and homemaking services.
LHIN/Hospital Information
Please Indicate RAI Scores (if being referred by LHIN)
Assessment Information (for all referring sources to complete)
What Support Activities are Required Throughout a 24hr Period?
Personal Hygiene:
Toileting:
Transferring/Turning:
Dressing/Undressing:
Preparing Meals/Assistance with Eating:
Medication Reminders:
Safety Check:
Exercise/Range of Motion:
Essential Light Housekeeping:
If yes, what Meals resources are required?
This field is required

Are these eligibility requirements met?

Client must be living independently and able to be left alone between visits
Client is medically stable
Client requires approximately 1.5 hr daily of intermittent support
Client does not pose a risk to self or others
Client's need for support with homemaking does not exceed the need for personal support (more IADLs than ADLs)
Client does not require specialized behavioural care or mental health support not provided by this service (physically combative, verbally abusive, etc.)
Minimum Age: 65 yrs
This field is required

Client Information

This field is required
Email (Confirmation and reminder emails will be sent here)
This field is required
This field is required
This field is required
This field is required
This field is required
Referral Source

Email

This field is required
Power of Attorney

Email

This field is required
Health Information
This field is required
This field is required
This field is required
This field is required
This field is required
This field is required

Hospital

This field is required

Please list and describe any allergies

This field is required

List all medication, and dosages per day

This field is required
This field is required

What other services have been initiated?

This field is required
Additional Information

If client doesn't require translation, indicate N/A:

Enter only if applicable:

Please provide for SDL referrals:

Send additional documentation online through Caredove, or separately via other methods (e.g., fax)

Add files

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

Submission complete

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

A confirmation message will be sent to - -

Summary

Reference #: -
  • Registrant:
  • Organization:
    Central Registry > Nucleus Independent Living
    Service:
    Supports for Daily Living: Central Registry Intake
    Inquiry Phone:
    1 (905) 281-4443

Tip: Referrals can be viewed by navigating to referrals in the top menu

Cancel