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Section 1 - REQUESTOR INFORMATION (PERSON FILLING OUT APPLICATION)

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Section 2 - Applicant

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Section 3 - Family Contacts

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Section 4 - Income

Primary Source of Income

Case Manager of primary income source, if government agency

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Section 5 - Agency Information

Government or social agencies you are a client of

Primary Agency or Organization

Secondary Agency or Organization

Other Agency or Organization

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Section 6 - Medical

Primary Medical Practitioner

Secondary Medical Practitioner

Other Medical Practitioner

Pharmacy

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Section 7 - Medical Conditions

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Section 8 - Consents and Sign

I, , client of SupportiveLiving.ca, presently residing at , in the city of , give permission to any and all agencies and organizations for the release of information to SupportiveLiving.ca and its staff pertaining to my personal information, including but not limited to housing, medical, financial, diagnosis, medications, clinical assessments and reports, and any other information relevant to my admission and ongoing placement at a SupportiveLiving.ca residential home. I have provided the above information to the best of my ability and know it to be true and correct. If any of the above information changes, I agree to notify the administration staff at SupportiveLiving.ca so that this information can be updated. The below signed understands that this application is for the sole use of SupportiveLiving.ca and will be used in accordance with the Privacy act. Any sharing of this information will be limited to the ongoing care of the resident and in case of emergencies. I hereby consent to the monitoring of my medication on a need-be basis and understand that medication compliance (if I am on any prescription medication) is mandatory to maintain resident status in any of SupportiveLiving.ca's Independent Supportive Living homes. I understand that for purposes of medication monitoring, my prescriptions will be transferred to the Pharmacy which SupportiveLiving.ca uses on a regular basis and hereby give my consent to SupportiveLiving.ca to requisition the transfer upon acceptance of my application. I have read and understand all of the above consents OR all of the above consents have been explained to me.

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