Linkage to Care – Case Management Referral Form

IMPORTANT NOTICE: We regret that the Linkage to Care Program is NOT accepting any referrals at this time.

Client Information

Name:
Date of Birth:
Can we leave a message?
Interpretation Required:

Alternative Contact

Aware of HIV status:

Program Selection & Streaming

Please select the program to which you are applying.(Required)
Please refer to description of the HFCS and HOP subprograms found on the Linkage to Care page.
Are you applying from a Fife House residential program:(Required)
Move-in Date (if applicable)

Referral Screening Questions

Fife House is committed to improving access and support for applicants who identify as Indigenous, Black, and/or a Person of Colour (IBPOC). Do you Identify as IBPOC?
Do you identify as belonging to the 2SLGBTQIA+ community?
Are you HIV positive?
Do you need access to HIV and/or medical care?
Are you currently in Toronto?
Have you had case management services in the past?
Are you currently experiencing houselessness (i.e. living on the street, couch-surfing, staying in a shelter, etc)?
Are you currently at risk of eviction?
Are you living with mental health and/or substance use issues?
Do you have current criminal charges?
Are you willing to connect with staff on a weekly basis to work on your goals (including but not limited to housing)?

Summary of Support Needs (Rate each item as: 1 – Low, 2 – Moderate, 3 – High, N/A – Not applicable)

Residence and Accommodation History

Are they aware of your HIV status?
If you are moving into a permanent housing unit, please indicate:
Move-in Date
New Address

Description of presenting situation and concerns based on Summary of Needs above:

Referral Source