mYplace - Service Provider Referral Form

mYplace Release of Information Signed and Attached:
Section 1 - Relationship Between Referring Worker and Applicant
How long have you been working with this individual?*
How often do you meet with this individual?*
What direct services/supports do you or your agency provide to this person? *
YesNo
What supports/services will your agency provide to this individual if they are accepted into mYplace?
YesNoyes, only during trial period

Section 3 - Barriers and Challenges
The following questions are intended to give us more information about some potential barriers or challenges faced by the applicant. Answering yes to these questions will not hinder the applicant’s chances of being accepted into the program. We ask that you include observations about the applicant’s willingness to make changes, seek supports and move forward through these challenges.

Please identify any of the following areas that you believe may require support.
A) Mental Health?*
Please include brief history, supports, struggles and any additional relevant info.
B) Substance Use?*
Please include brief history, supports, struggles and any additional relevant info.
C) Legal?*
Please include any current outstanding charges, upcoming court dates, potential arrest warrants, Bail/probation conditions and any additional relevant info.
D) Emotional Responses/Anger?*
Please include any concerns you have regarding the applicant’s ability/willingness to manage their emotional responses/anger and any additional relevant info.

Section 4 – Need for Support
A) What are the reasons you are referring this individual to mYplace (outside of them identifying as 2SLGBTQIA+)?*
B) In your opinion are there additional supports you would recommend the applicant access in order to be successful at mYplace? If yes, please be specific.*
C) Do you have another plan if your client is not accepted into mYplace? If so what other options are you exploring? *
D) Additional comments

Referring Worker’s Agreement Statement
I have read through the mYplace referral package and understand mYplace criteria for acceptance. I have advised my client that this is an application and interview process that will determine which applicant will best meet the suitability criteria. I have also advised my client that there is a program agreement that they will have to sign if they are accepted into mYplace. I plan on continuing to work with this client towards a plan of action while this application is processed.*

Agreed
Should be Empty:

Rows	Yes	No
Cook for themselves?
Shop for food and other supplies?
Keep their room clean?
Wash dishes?
Wash clothes?
Wake up by themselves?
Is able to budget money?
Keep track of appointments

Referring Worker Information