REFERRAL TO GRACE HOUSE
(to be completed by referring worker)
Only those accepted for an interview will be contacted. Successful applicants will be considered for admission based upon a priority and suitability assessment, as opposed to the order in which received.
		residential services
		community case management
Send to: Grace House c/o 130 Cornwall Rd., Oakville L6J 7V8
NAME ADDRESS LIVING ARRANGEMENT single/family/shared/other
DATE OF BIRTH SEX MARITAL STATUS
REFERRING WORKER REFERRING AGENCY TELEPHONE
MEDICAL DOCTOR PSYCHIATRIST COUNSELLOR
OTHER AGENCIES INVOLVED 1. 2. 3.
DIAGNOSIS/PRESENTING ISSUE(S):
PHYSICAL/MEDICAL FACTORS (check where applicable):
1.	Physical Illness		5.	Speech
2.	Physical Handicap		6.	Hearing
3.	Allergies		7.	Vision
4.	Developmental Handicap		8.	Medication Required
Please expand on above:

PERSONAL FACTORS (check where applicable):
1.	Appearance	11.	Sleeping Difficulties
2.	Motivation	12.	Criminal Justice Involvement
3.	Social Skills	13.	Peer Relationships
4.	Alcohol	14.	Family Relationships
5.	Drugs	15.	Dependants
6.	Depression	16.	Community Involvement
7.	Mood Swings	17.	Attitude Towards Medication
8.	Violence	18.	Psychiatric Symptomatology
9.	Daily Activities	19.	Physical/Sexual Abuse
10.	Suicidal Activity	20.	Other:
(Additional Information Relevant to Applicant’s Current Functioning Is Required)
Please expand on above:
CIRCUMSTANCES LEADING TO CONTACT WITH REFERRING AGENCY:
DAY PROGRAM WHILE AT GRACE HOUSE:

EDUCATION:
1) To Date:
2) Future Plans:
LEGAL HISTORY (check where applicable):
1.	Criminal Record	3.	Police Involvement
2.	Criminal Charges	4.	Other legal issues
Please expand on above:
VOCATIONAL HISTORY:
1) Previous or Present Employer(s):
2) Steadiness of Employment:
3) Motivation for Future Employment:
FINANCES:
1) Source:
2) Management:

WORKER’S GOALS FOR APPLICANT:
REFERRING AGENCY RESPONSIBILITIES:
PERSON(S) RESPONSIBLE FOR CONTINUING CONTACT:
OTHER RESOURCES:
1) Present:
2) Future:
ADDITIONAL COMMENTS:
DATE:	SIGNATURE: