Application for Inclusio Residency

Inclusio is Accessible Housing’s 45-unit home which provides a supportive living environment where residents can thrive. Before filling out this tool, please carefully read the Inclusio section of our website where you will find very important information about the Inclusio program, rent structure, supports available, and other details about living at inclusio. This information will help you best understand what Inclusio offers, and whether residency at Inclusio is suitable for you.

In completing this application for residency at inclusio, please provide as detailed information as possible. Please put "NA" if not applicable for mandatory sections within the form.

Please note that this is only the first step in the application process. Upon receipt of your application, the Inclusio Intake team will inform you of the next steps in your application process, and what else is required of you. If you need clarification about the information on this application form, please email intake@accessiblehousing.ca

Alternatively, you may download the pdf form and fill out by hand. Please email the completed form to intake@accessiblehousing.ca

Eligibility Criteria

Inclusio is best suited for residents who are self-motivated, willing to maximize their independence, and enjoy a congregate living environment. Before continuing with this application, please read through the criteria to determine if living at Inclusio would be suitable for you.

Please tick as appropriate. Y or N

Are you over the age of 18?

Yes No

Do you have limited mobility due to a permanent, congenital or acquired physical disability?

Yes No

Do you regularly use a prescribed mobility aid, safely and independently?

Yes No

Do you have a history of falls leading to significant injuries, that cannot be managed on an ongoing basis?

Yes No

Are you medically stable and do not require constant, 24/7 interventions that cannot be supported by AHS Home Care?

Yes No

Do you have a significant memory / cognitive impairment (Dementia, Alzheimer’s) and cannot be your own decision maker and manage their own personal affairs?

Yes No

Do you require regular nursing interventions (i.e. PICC lines, IVs, complex wound care)?

Yes No

Do you experience seizures?

Yes No

Do you have significant swallowing problems that could pose a choking risk or require a modified diet (i.e. thickened fluids or puree)?

Yes No

Can you administer your medication – on your own as prescribed by a physician? If not, are you willing to engage in a medication administration program developed by either AHS Home Care or Accessible Housing?

Yes No

Can you take personal responsibility to ensure they receive proper medical care as required and all medical recommendations?

Yes No

Are you interested in living in a congregate living environment

Yes No

Are you respectful in your interaction with other residents and staff?

Yes No

Will you participate in regular reviews of service plans, assessments and care plans?

Yes No

Will you comply with all laws, regulations and policies about the health, sanitation and safety of other residents and staff?

Yes No

Do you have any unresolved legal issues that involve any potentially dangerous or criminal behaviors?

Yes No

Are you motivated towards personal growth and/or acquiring the skills necessary to maximize independence.?

Yes No

Do you require some degree of support around activities of daily living (bathing, toileting, clothing, grooming, meal assistance) and personal care assistance?

Yes No

Applicant Information

Please complete all sections and provide information for each question to enable us have a good understanding of who you are. If a question does not apply, please write in N/A.

First Name

Last Name

Birth Date

Current Home Address

Phone

Date of Application

Secondary Contact (i.e. family member, caregiver, etc.)

First Name

Last Name

Phone

Referral Source (i.e. if referral through social worker, occupational therapist, etc.)

First Name

Last Name

Phone

1. Please describe your permanent mobility challenge. Is your condition stable or progressive?

2. What mobility aides do you use? With what frequency and for what activities? Can you independently use your mobility aide (without help from anyone)?

3. Describe how you currently self-direct your care – i.e. give directions to care staff about the assistance you need and make decisions about your care.

4. Do you have a Guardianship or Power of Attorney in place? If yes, please provide details.

5. Are you able to fully understand and independently manage your medications?

Communicate with the pharmacy

Yes No

Arrange medication pick up or drop off

Yes No

Safely store medications as required

Yes No

Use medication according to physician’s prescriptions

Yes No

Notify Homecare and Inclusio about changes to your medication

Yes No

6. Inclusio is a congregate living environment characterized by some sharing of public-use spaces and amenities. Please indicate any apprehension or challenges you might have with living in this type of environment.

7. Describe your current living situation, highlighting the current challenges you are experiencing there and why you want to move.

8. Describe your expectations for living at Inclusio and the value you hope living at inclusio might provide for you.

9. Inclusio allows residency for licensed service dogs, not pets, companion or emotional support animals. If you currently have one, what supports would you need with your service dog?

10. Have you been or are you a current Homecare client?

Yes No

11. Do you have other people (staff, family members) providing support to you on a regular basis? If yes, please provide details.

Yes No

Please provide details.

12. What activities of daily living do you need assistance with?

Bathing/showers

No assistance needed Some assistance needed Total assistance needed