ErinoakKids - Respite Pre-Admission Form

RESPITE PRE-ADMISSION FORM

Required fields are marked with an asterisk (*) unless otherwise specified.

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PARENT/LEGAL GUARDIAN INFORMATION

Person to Notify (primary contact - will be the only person notified for services)*

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Has your family member attended ErinoakKids’ Respite Program in the last 2 years?*

Yes No

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ALL ABOUT YOUR FAMILY MEMBER

What would you like us to know about the important people in your family member's life?*

What are your family member’s play skills, preferred toys or leisure skills?*

What are your family member’s strengths and abilities?*

What are things your family member dislikes?*

How does your family member communicate? (please select all that apply)*

Words Gestures Sounds Sign Language Alternative Augmentative Communication Pictures/Symbols

Other (describe)

What culture does your family member identify with?*

Does your family member identify as First Nations, Inuk or Metis?*

Yes No

What spirituality does your family member identify with? (e.g. Catholic, Protestant, Christian, Muslim, etc) (optional to answer)

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MEDICAL NEEDS

G-Tube, GJ-Tube or J-Tube

Vision and Hearing

Does your family member have an antibiotic resistant organism such as MRSA, VRE, or c-difficile?

Yes No

Does your family member have an updated Tetanus vaccination?

Yes No

Does your family member have allergies?

Yes No

Please describe your family member’s underlying medical diagnosis/diagnoses (if known)

Please describe any recent illnesses, hospitalization and surgeries

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SOCIAL AND EMOTIONAL NEEDS

Are there any development, emotional social, psychological needs that would be important for the Respite staff to know about your family member? (e.g., anxiety, suicidal ideation, depression)*

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DAILY CARE REQUIREMENTS

Medication Administration of scheduled medications and vitamins/supplements

Medication Administration for as needed medication (e.g., Tylenol)

Consent to contact pharmacy*

Yes No

Please select all that apply:*

Pain and symptom management

Skin Care Routine

Additional Monitoring

Does your family member have a shunt in their brain?

Yes No

Other Daily Requirement(s):

Does your family member require assistance in the following areas?

Please describe all that apply:*

Toileting

Bathing (If your family member is staying overnight)

Dressing

Mealtimes

Bedtime (If your family member is staying overnight)

Mobility

Swimming

A Personal Assistance Service Device (PASD) is specialized equipment to assist with hygiene, washing, dressing, grooming, eating, drinking, elimination, ambulation or positioning or any other routine activity of living. PASDs may include orthotics, wheelchairs, helmets, standers and walkers.

Upon admission, a consent form will be completed to identify a plan to use PASD and to ensure PASD is in good working order.

Does family member wear braces/orthotics?*

Yes No

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BEHAVIOURAL NEEDS

Would your family member benefit from a Safety Plan during their visit? Please describe/share

Does your family member demonstrate any of the following?

Does your family member demonstrate aggression towards others?*

1 to 3 times/day 1 to 3 times/week 1 to 3 times/month None of the above

Does your family member demonstrate aggression towards themselves?*

Requires medical treatment Requires first aid-treatment Does not require treatment None of the above

Does your family member try to leave the house on their own?*

1 to 3 times/day 1 to 3 times/week 1 to 3 times/month None of the above

Does your family member engage in property destruction?*

1 to 3 times/day 1 to 3 times/week 1 to 3 times/month None of the above

Does problem behaviour occur when you break routine or interrupt activities?*

Yes No

Does problem behaviour occur when it appears that your family member will not get their way?*

Yes No

Does problem behaviour occur when you ask your family member to do something they do not want to do?*

Yes No

Does problem behaviour occur when your family member wants your attention?*

Yes No

How do you know problem behaviour is going to happen? List the behaviours your family member engages in before the onset of problem behaviour*

How do you calm your family member down once they engage in the problem behaviour?*

What actions do you do to distract your family member from engaging in the problem behaviour?*

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OTHER INFORMATION

Is there any other information that is relevant for the Respite Staff to know about your family member?*

Name of person completing the application:

Person to Notify Next of Kin Other

GENERAL CONSENT

This information is being submitted with the knowledge and consent of the parents/legal guardians. By providing the contact information with the form(s), you consent to receiving information about new service offerings, fundraising initiatives and free events offered at ErinoakKids by email, post, SMS/Text and other electronic means. ErinoakKids will always treat your personal details with the utmost care and will not share or sell your personal information. You may unsubscribe from receiving communications from ErinoakKids at any time. We are committed to keeping your information safe and confidential. We follow the rules set out in law about collecting, using and disclosing your personal information. For more information, please review our privacy policies publicly posted at https://www.erinoakkids.ca/privacy.

Consent Received:*

Yes No

If No, ErinoakKids will not process this referral.

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