"Application for Temporary Placement of a Vulnerable Person in a Developmental Centre for Respite Care" - Manitoba, Canada

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Office of the Vulnerable Persons’ Commissioner
Application for Temporary Placement of
a Vulnerable Person in a Developmental
Centre for Respite Care
Under The Vulnerable Persons Living with a Mental Disability Act (the Act), certain requirements must be
met for a substitute decision maker to temporarily place a vulnerable person in a developmental centre
for respite care.
The requirements that must be met are that:
• the substitute decision maker for personal care has been granted power under clause 57(2)(a)
of the Act to decide where the vulnerable person is to live
• the purpose of the placement is to provide respite care for the vulnerable person
• the vulnerable person requires a level of care that is not readily available outside a
developmental centre
• there is a developmental centre willing to accept the vulnerable person, and
• the temporary placement of a vulnerable person in a developmental centre does not exceed
three weeks in a year
If you need more space to complete your answers, please attach a separate page and include the
section numbers (ex. 3.1).
Ce formulaire de demande existe également en français. Composez le 204-945-5039 ou le 1 800 757-9857
(sans frais).
PART 1 INFORMATION ABOUT THE VULNERABLE PERSON
1.1
About the vulnerable person
Last name
First name
Middle name
_________________________________
__________________________________
______________________
Birth date (mm/dd/yyyy)
______________________________________________________________________________________________
Address (street number, street name, town/city, province, postal code)
______________________________________________________________________________________________
Mailing address, if different from above (street number, street name, town/city, province, postal code)
______________________________________________________________________________________________
1.2
Vulnerable person’s social worker/case co-ordinator (if known):
__________________________________________________________________________
Name
__________________________________________________________________
Mailing address
___________________________________
______________________
(
)
(
)
Phone number
Fax number
1
Office of the Vulnerable Persons’ Commissioner
Application for Temporary Placement of
a Vulnerable Person in a Developmental
Centre for Respite Care
Under The Vulnerable Persons Living with a Mental Disability Act (the Act), certain requirements must be
met for a substitute decision maker to temporarily place a vulnerable person in a developmental centre
for respite care.
The requirements that must be met are that:
• the substitute decision maker for personal care has been granted power under clause 57(2)(a)
of the Act to decide where the vulnerable person is to live
• the purpose of the placement is to provide respite care for the vulnerable person
• the vulnerable person requires a level of care that is not readily available outside a
developmental centre
• there is a developmental centre willing to accept the vulnerable person, and
• the temporary placement of a vulnerable person in a developmental centre does not exceed
three weeks in a year
If you need more space to complete your answers, please attach a separate page and include the
section numbers (ex. 3.1).
Ce formulaire de demande existe également en français. Composez le 204-945-5039 ou le 1 800 757-9857
(sans frais).
PART 1 INFORMATION ABOUT THE VULNERABLE PERSON
1.1
About the vulnerable person
Last name
First name
Middle name
_________________________________
__________________________________
______________________
Birth date (mm/dd/yyyy)
______________________________________________________________________________________________
Address (street number, street name, town/city, province, postal code)
______________________________________________________________________________________________
Mailing address, if different from above (street number, street name, town/city, province, postal code)
______________________________________________________________________________________________
1.2
Vulnerable person’s social worker/case co-ordinator (if known):
__________________________________________________________________________
Name
__________________________________________________________________
Mailing address
___________________________________
______________________
(
)
(
)
Phone number
Fax number
1
PART 2 INFORMATION ABOUT THE APPLICANT (SUBSTITUTE DECISION MAKER(S) FOR
PERSONAL CARE)
1. Name of substitute decision maker for personal care
__________________________________________________________________________________________
Mailing address
__________________________________________________________________________________________
(
)
Phone number ____________________________________________________________________________
2. Name of joint substitution decision maker for personal care (if applicable)
__________________________________________________________________________________________
Mailing address
__________________________________________________________________________________________
(
)
Phone number ____________________________________________________________________________
PART 3 REASON(S) FOR THE APPLICATION OF TEMPORARY PLACEMENT IN A
DEVELOPMENTAL CENTRE
3.1 Explain why a request is being made for the temporary placement of a vulnerable person in a
developmental centre.
3.2 Describe why you believe the vulnerable person requires a level of care that is not readily
available outside a developmental centre.
2
PART 4 TEMPORARY PLACEMENT OF A VULNERABLE PERSON IN A DEVELOPMENTAL
CENTRE
4.1 List any periods of temporary placement in a developmental centre that have occurred for
the vulnerable person during the past 12 months.
4.2 Indicate what time period(s) is/are being requested for the temporary placement of the
vulnerable person in a developmental centre.
SIGNATURE OF SUBSTITUTE DECISION MAKER(S)
Signature of Substitute Decision Maker(s)
Date
___________________________________
___________________________________
___________________________________
___________________________________
Note: Incomplete application packages will take longer to process.
Send the completed application and supporting documents to:
Office of the Vulnerable Persons’ Commissioner
315-258 Portage Avenue
Winnipeg, Manitoba R3C 0B6
Telephone: 204-945-5039
Toll Free: 1-800-757-9857
Fax: 204-948-3713
3
TO BE COMPLETED BY THE DEVELOPMENTAL CENTRE
1. The vulnerable person
Name of vulnerable person for whom temporary placement is requested
_________________________________________________________________________________________________
2. Name of developmental centre
Name of developmental centre
Contact person
____________________________________________________
_____________________________________
Position
Phone number
(
)
____________________________________________________
_____________________________________
3. Period(s) of acceptance
Outline what period of time you are willing to accept the vulnerable person in the developmental
centre.
4. Prior Temporary Placements
Has there been a temporary placement period for the placement of the vulnerable person in a
developmental centre during the past 12 months?
Yes
No
If yes, list the placement period(s) below:
SIGNATURE OF AUTHORIzED DEVELOPMENTAL CENTRE STAFF
Signature of Authorized Developmental Centre Staff
Date
__________________________________________________________
________________________________
4
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