Fillable APPLICATION FOR MONROE COUNTY OASAS RESIDENTIAL SERVICES

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APPLICATION FOR MONROE COUNTY OASAS RESIDENTIAL SERVICES

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Universal OASAS Residential Application, June 2009, Page 1
APPLICATION FOR MONROE COUNTY OASAS RESIDENTIAL SERVICES
UPDATED 07/03/2019 APPLICANT INFORMATION
Last Name: (Maiden) First Name: Middle Initial:
TA Application Submitted? Yes No Which County? _____________ ARES Request Done? Yes No
Medicaid Managed Care Application Submitted? Yes No Date _____________
Gender: Male Female Transgender Have you ever been in the military? Yes No
Date of birth: SSN:
Your Phone # where you can be reached now
and after discharge (if inpatient):
May We Leave a Message: Yes No
Current address: City: Zip Code:
1. Please check your housing situation at the time of this application:
Homeless
Living in Shelter
Private Residence
Other OASAS/OMH Residence
Correctional Facility
Hospital/Inpatient (please ensure contact
number is on this referral to assist with
contacting you after discharge)
Other (describe):
2. Do you inject non-prescribed drugs using a needle/syringe? Yes No
3. For women: Are you pregnant at this time
? Yes No
4. Medical Problems:
5. Mental Health (past 6 months): Suicidal Ideations Yes No Homicidal Ideations Yes No
6. Current Legal involvement? Yes No Describe:
CURRENT SERVICE PROVIDER INFORMATION
Please provide the information below for the service(s) you presently receive
Inpatient: Phone:
Counselor Name: Fax:
Stabilization: Phone:
Counselor Name: Fax:
Rehabilitation: Phone:
Counselor Name: Fax:
Outpatient Substance Use Treatment: Phone:
Counselor Name: Fax:
Inpatient Mental Health Agency: Phone:
Counselor Name: Fax:
Outpatient Mental Health Agency: Phone:
Counselor Name: Fax:
Care Management Agency: Phone:
Case Manager Name: Fax:
Primary Care Physician: Phone:
Address: Fax:
Universal OASAS Residential Application, June 2009, Page 2
*PLEASE ATTACH THE FOLLOWING OR HAVE YOUR MOST CURRENT PROVIDER SEND THIS INFORMATION*
ATTACHED
1. Most recent psychosocial/evaluation
for substance use and mental health disorders with
DSM diagnoses
Yes
No
2. Most recent history and physical *** Yes
No
3. Most recent laboratory results including complete blood count and differential, routine
and microscopic urinalysis, urine screen for drugs ***
Yes No
4. Most recent TB (Tuberculosis) screening (PPD or Chest X-Ray) ***
Yes No
5. Consent for Release of Information Between Current Service Provider and Residential
Provider
6. Copy of LOCADTR indicating residential level of care needed for accurate Waiting List
placement and ARES approval
*PLEASE NOTE-The referring outpatient/inpatient therapist must make the request
Yes No
Yes No
for residential services in ARES when the person is pending/receiving DHS temporary assistance*
***If you have not had a history and physical, the required lab work, and/or TB screening done within
the past 12 months, please schedule them immediately.***
PLEASE ANSWER YES OR NO THE FOLLOWING STATEMENTS
1. I need services for my substance use disorder. Yes
No
2. I believe that I am free of any communicable (infectious) disease that can be spread
by ordinary contact.
Yes No
3. I believe that I need acute hospital care right now.
Yes
No
4. I have thoughts of hurting others or myself at this time.
Yes No
5. I am experiencing serious withdrawal symptoms at this time.
Yes No
6. I have experienced withdrawal seizures or “DT’s” in the past.
Yes No
RENT/PAYMENT
Wages/Other Income
Please provide monthly income including a pay stub. Monthly income
: $
Please check source of income: Family Wages Unemployment Pension Trust Fund
If you do not have any wages/SSI/SSD or other income, please apply for TA/cash assistance immediately
.
DHS Funding-Temporary Assistance/Medicaid
I applied for full cash assistance on:
DHS Case #: BA
Medicaid #
Status of DHS case:
Phone #:
If you are not approved for DHS cash assistance you will remain responsible for the rent.
SSI/SSD
Please check the type of social security you are receiving: SSI SSDI
Please provide monthly SSI/SSDI income. Monthly SSI/SSDI income: $
If you have a Rep Payee, please provide the name and phone number below:
NAME:
AGENCY: PHONE:
Universal OASAS Residential Application, June 2009, Page 3
DESCRIPTION OF RESIDENTIAL SERVICES FOR WHICH YOU ARE APPLYING
Stabilization (Intensive Residential): I would benefit from 24-hour supervised setting to successfully maintain
abstinence, participate in treatment, and achieve lasting recovery in a more independent setting. Services provided
within the facility include medical and psychiatric care, nursing services, vocational services and clinical groups.
Rehabilitation (Intensive Residential): I am not experiencing cravings or withdrawal symptoms. If applicable my physical
and mental health are stable. Services provided include support with emotional regulation, interpersonal skills and social
role functioning.
Community Re-Integration (Community Residence): I am living in an environment not conducive to recovery and need a
24-hour supervised setting and/or other support services such as engagement in outpatient treatment services,
vocational or educational services, medication management, and a structured environment.
Community Re-Integration (Supportive Living): I require residential support that provides a substance free
environment; I require peer support to maintain abstinence; I don’t require 24-hour on-site supervision; I exhibit the
skills to maintain abstinence and readapt to independent living as evidenced by engagement in recovery related services
including outpatient continuing care, attendance at self-help or community related supports, engagement in volunteer
and or work related activities.
When referring to a residential setting please consider the following placement questions:
_____ What level of care does the LOCADTR 3.0 indicate?
_____ Does the person have serious psychiatric or medical symptoms that would require 24-hour psychiatric or medical
oversight? Is the person using substances with risk of medical complications from withdrawal or risk of Overdose?
_____ Does the person have the ability to tolerate group living? Does the person have any interpersonal or personal
skills deficits that would cause disruption or harm in a congregate setting? Does the individual have a history of physical
violence, aggression or exhibit predatory behavior?
When referring to a residential setting please refer to Level of Care indicated on LOCADTR.
Universal OASAS Residential Application, June 2009, Page 4
CatholicFamilyCenter
StabilizationFreedomHouse(male)IntakeCoordinator,JohnBarbaro(585) 546‐7220,ext.5030,Fax(585) 423‐
2201StabilizationLibertymanor(female)IntakeCoordinator,EmilyPrice(585) 546‐7220,ext.5053,Fax(585) 423‐
2201RehabilitationFreedomHouse(male)IntakeCoordinator,JohnBarbaro(585) 546‐7220,ext.5030,
Fax(585) 423‐2201
StabilizationLibertymanor(female)IntakeCoordinator,EmilyPrice(585) 546‐7220,ext.5053,Fax(585) 423‐2201
CommunityResidenceAlexander&Jones(male)IntakeCoordinator,JohnBarbaro(585) 546‐7220,ext.5030,
Fax(585) 423‐2201
CommunityResidenceBarrington(female)IntakeCoordinator,EmilyPrice(585) 546‐7220,ext.5053,
Fax(585) 423‐2201
SupportiveLivingIntakeCoordinator,JohnBarbaro(585) 546‐7220,ext.5030,Fax(585) 423‐2201
EastHouse
CommunityResidenceJocelynDixon,Admissions(585) 238‐4810
Fax(585) 238‐8998,j.dixon@easthouse.org
SupportiveLiving(men,women,familywithchildren):JocelynDixon,Admissions(585) 238‐4810
Fax(585) 238‐8998,j.dixon@easthouse.org
PathwayHousesofHelioHealth,Inc.
SupportiveLivingDeanna Cappon,TeamLeader,1350UniversityAve.Phone:(585)232‐4674
Fax:(585)325‐5001website:pwhouses.orge‐mail
dcappon@helio.health
RochesterRegional
YoungMen’sCommunityResidence(servingmaleyouth):AnnaKennedy,AdmissionsCoordinator.
Phone(585) 723‐7959,Fax(585) 723‐7353
Women’sCommunityResidenceBarbaraWolkSchwarz(servingwomenonly):IntakeCoordinator,
Phone(585)723‐7717,Fax(585)723‐7358
VillaofHopeYoungMen’sCommunityResidence(servingmaleyouth):LynsayDiaz
Phone(585)328‐0834,Fax(585)436‐0103cdclinic@villaofhope.org
YWCA
SupportiveLiving(womenaloneORwithchildren):AmyWells,
Phone(585)368‐2225,Fax(585)232‐3540awells@ywcarochester.org
Universal OASAS Residential Application, June 2009, Page 5
Veteran’s Outreach Center
Supportive Living (male veterans only): 290 South Avenue, Rochester NY 14620, Alec
Andrest
Alec.Andrest@vocroc.org Phone (585) 506-9060, Fax : (585) 506-9063
If being completed with the assistance of another individual, please complete:
Name of Agency person
Assisting with application:
Agency:
Date:
Signature of Applicant (person seeking residential service):
D
ate:
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APPLICATION FOR MONROE COUNTY OASAS RESIDENTIAL SERVICES

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Completed 22 January 2021

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