Algonquin Child & Family Services

Intensive Service Coordination (ISC)

ISC may be accessed by an agency that has been working with the child/youth and family, to support the child/youth with complex special needs at a systems level. A goal will include transitioning the child/youth and family back to the existing service system with the continuation of supports, services, and a community case manager monitoring the developed integrated service plan. ISC is a time-limited service.

 Before you begin with the screening process, please be aware that Intensive Service Coordination is not a first point of entry to the service system. It is used once efforts have been made to meet a child/youth’s needs through funded services and agency level service coordination.

Please check that the following apply before you continue with the screen form:

More than one service is involved, has been involved for a period of time, and has been working towards meeting the needs of the child/youth & family through a service/treatment plan and through agency level service coordination

Referrals have been completed or are in progress for all Ministry funded services/supports that the child/youth & family would qualify for

A community case manager (CCM) has been identified/discussions are occurring to identify a CCM

 Part 1 and 2 of the screen form must be completed

 This form must be signed by the parent/legal guardian AND a referral source - referrals not signed by either party will result in the form being sent back to the service provider

 Once the screening form has been received, a phone call will be scheduled with the referring service provider. *Please be prepared to review the items checked-off and provide details of how the client meets all of the following criteria; o A) meets the definition of complex special needs, o B) requires specialized services and supports to enhance their health, development and participation, and o C) that the family would benefit from an an extraordinary service response beyond what is currently available to them in the service system

 If it is determined that the child/youth meets the above criteria, the service provider and family will be contacted by the assigned Intensive Service Coordinator to complete the intake process. 2

 Note: Please inform your immediate supervisor/manager if ISC becomes involved with a client/service team, as it is the responsibility of all service providers involved to contribute their expertise and appropriate resources to the process. Service providers should also be prepared to flex mandates and make resources available to help support the integrated service plan, and this may require a decision maker to be present at meetings for this to occur. Immediate supervisors/managers should also be made aware if the team is seeking to have the case reviewed through the case resolution process.

DEFINITIONS

Children/youth with Special Needs are defined as:  Having functional limitations in life activities as a result of impairment in one or more of the following areas: Physical, developmental, social/emotional/behavioural, mental health, cognition, communication, sensory, motor or health  And need specialized services and supports to enhance their health, development, or participation in activities at home, in school or in their communities

Children/youth with Complex Special Needs are children with special needs, who:  Often have high needs stemming from significant functional limitations  And whose families have sought services but are experiencing significant stresses and report an inability to manage the care needs of their child  And who would benefit from an extraordinary service response beyond what is currently available to them in the service system, that includes cross-agency service planning and coordination involving the relevant sectors (e.g. health, education and social services), resulting in an integrated service plan and flexible use of service resources

o Many of these children and youth have significant behavioural challenges or need constant care or supervision. In some cases, the family situation is the most significant factor leading to the need for an extraordinary service response o Examples of family situations include limited resources, parental illness, more than one child with special needs 3 Private & Confidential 4

Screen Form

Client Name: DOB: Date of referral: Male Female Name of Parent(s)/Guardian(s): Name of Referring Agency: Home Address: Name of Agency Representative: Address: Telephone #: Home: Work: Telephone #: Case Manager: Is the service team aware of referral?: Yes No Part 1: Please check-off all applicable items

A. ELIGIBILITY – client meets criteria for complex special needs (refer to definition on page 2):

Child/youth with special needs

Has high needs stemming from significant functional limitations

Requires specialized services/supports to participate in activities of daily living on a long-term, continuous and/or intermittent basis

Whose family has sought services but is experiencing significant stresses or report an inability to manage the care needs of their child

Would benefit from an extraordinary service response beyond what is currently available to him/her in the service system, that includes cross-agency service planning and coordination involving the relevant sectors (e.g. health, education and social services), resulting in an integrated service plan and flexible use of service resources

Has significant behavioural challenges or need constant care or supervision

The family situation (e.g. limited resources, parental illness, more than one child with special needs) is the most significant factor leading to the need for an extraordinary service response.

Briefly describe each item checked off:

B. CHILD’S NEEDS:

is in significant developmental transition stage

has three or more challenges related to his/her special needs.1 Private & Confidential 5

Client Name: DOB:

has chronic sleep disturbances

recently been hospitalized and requires additional care

requires constant 24 hour supervision or care beyond that which is developmentally appropriate

C. RISK OF HARM TO SELF, OTHERS OR PROPERTY:

exhibits ongoing/ spontaneous and/or unexplained self-destructive behaviour resulting in harm to self

exhibits ongoing/spontaneous and or unexplained aggressive behaviour resulting in harm to sibling, caregivers or others

exhibits frequent, ongoing and severe behavioural problems

has frequently damaged property

domestic violence exists in the home

is vulnerable to harm from others

Breifly describe each item checked off:

D. FAMILY SITUATION:

primary caregiver has few or no family supports to help in managing the child’s care needs

little or no identified informal or social support system available to the family

family activities are significantly affected by the child’s special needs

siblings’ personal/social life or well-being are significantly affected by the child’s special needs

recent significant family event or environmental change

family has identified that they are experiencing significant stress

other children in the home with special needs

1 For example: medical, physical, emotional, mental health, intellectual, behavioural, social. Private & Confidential 6

Client Name: DOB:

caregiver(s) are feeling overwhelmed

caregiver(s)’ emotional stability, developmental status, cognitive limitations, mental or physical health affects their current ability to care for the child

caregiver(s) are at risk of job loss due to the care needs of the child

limited family resources available to address the needs of the child

E. SYSTEM INVOLVEMENT:

family is receiving multiple services

the complexity of the service needs for the child/youth and family are beyond the capacity of the service system and family to address

school placement has broken down, is at risk of breaking down, or is required but currently unavailable

conflicts/disagreements between caregiver(s) and service providers that are creating stress for the family

need for long-term on-going intensive supports

family is unable to access culturally appropriate services/service providers

caregivers have turned down services that have been offered as they have not considered them to be appropriate to their needs or preferences

various services or supports have been identified as needed, including those from other sectors but these are not available to the family

family is using all the appropriate services and supports that are available to them, including those from other sectors but these are not sufficient to reduce serious forseeable risk

Briefly describe each item checked off: Private & Confidential 7

Client Name: DOB:

Part 2: Please answer the questions below and provide any further details that will assist us in determining eligibility (attach a separate sheet if required).

1. Describe the efforts made to meet the needs of the child and his/her family through:

a) Funded Services (eg. Services through FYCSM, Hands, OKP, Community Living; as well as funding accessed such as SSAH, ACSD, Respite funding, etc.)

b) Agency level service coordination (eg. Referrals completed, date of last team meeting/case conference and outcomes, etc.)

What would you like to see happen as a result of your involvement with Intensive Service

Coordination? You can include the goals to be achieved and the services and supports that are

required.

______

______Consent to Agencies Involved Past Present Name of Role\Focus of Exchange Contact/phone Service Information number and/or email address

Community Living Children’s Aid Society Children’s Rehabilitation Services Community Action Program for Children Private & Confidential 8

Client Name: DOB: Community Care Access Centre Community Counseling Centre Children’s Hospital of Eastern Ontario Developmental Support Services Family Enrichment Family Youth and Children’s Services Healthy Babies/Healthy Children Infant Development Program IBI Program/Autism Services Hands TheFamiyHelpNetwork.ca Health Unit One Kid’s Place Psychologist Resource Teacher Program (preschool age) School (include name of school) Sick Kids Hospital Other (please specify) :

Private & Confidential 9

Client Name: DOB: CONSENT TO EXCHANGE INFORMATION

I, ______, hereby give consent to Hands TheFamilyHelpNetwork.ca or Family, Youth and Child Services of Muskoka Name of Client/Parent/Guardian to release to/or request from the above indicated agencies/professionals information pertaining to ______Name of Client/Parent/Guardian / D.O.B. for the purpose of: determining eligibility for Intensive Service Coordination.

In the process of gathering information to determine eligibility for this referral, both agencies must meet the requirements of provincial legislation relating to the privacy of your information. In signing this consent you agree that collecting, storing and disclosing your child’s health information is consistent with the Personal Health Information and Privacy Act of Ontario (2004) (PHIPPA) and the Agency’s privacy statement, except where required by law.

Your child’s information, collected in this referral form, will be placed in a common data base

This consent shall remain in effect from this date until the purpose for which the information was disclosed has been achieved but no longer than one year from the date of my consent. It is understood that I can revoke this agreement at any time either verbally or in writing.

______Signature – Client 12 years of age or older

______Signature – Parent/Guardian(s)

______Signature of Witness

DATED THE ______OF ______, 20_____ DAY MONTH YEAR

EXPIRY DATE: (maximum of one year) ______OF ______, 20_____ DAY MONTH YEAR

The following signature confirms our agreement to actively participate in the development and implementation of an integrated service plan through resource commitment and flexible use of resources, as deemed necessary.

Name of referral source: Position: Signature: Date:

(Forms\consent-authorizationforms\consent to exchange information) Rev. Nov. 24/03) D:\Docs\2018-04-15\05845637fe2174c923ea599813d5bb1f.doc Private & Confidential 10

Client Name: DOB: Please attach original Consent to Exchange Information Form completed by referral source to: North Bay, Sturgeon Falls, Mattawa: Parry Sound: Hands The Family Help Network.ca Hands The Family Help Network.ca 222 Main Street East 2 May Street, Suite A North Bay ON P1B 1B1 Parry Sound ON P2A 1S2 Telephone: (705)476-2293 Telephone: (705)746-4293 Fax: (705)495-1373 Fax: (705)746-7600 Sundridge: Bracebridge and Huntsville: Hands The Family Help Network.ca Family Youth and Children’s Services 37 Main Street of Muskoka Sundridge ON P0A 1Z0 49 Pine Street Telephone: (705)384-5225 Bracebridge ON P1L 1K8 Fax: (705)384-5808 Telephone: (705)645-4426 Fax: (705)645-1905

Office Use Only:

Date Received: